Point-of-Care Respiratory Virus Testing Encounter Note

Date/Time: [Encounter date and time]

Setting: [clinic / urgent care / ED / telehealth]

Provider: [Name, credentials]

Subjective

Chief Complaint: [Chief complaint in patient's words]

[Brief HPI narrative] (Include: symptom onset date and calculated day of illness; overall course [improving / worsening / stable]; key respiratory symptoms; red flags asked about—dyspnea at rest, chest pain, confusion, severe weakness; relevant exposures and any prior testing. If onset date is unknown, state "Onset: unknown" with brief explanation. Use "denies fever" or "subjective fever" rather than "afebrile" unless temperature was measured.)

Risk Factors for Severe Disease: [Age-related risk / pregnancy / immunocompromise / chronic cardiopulmonary disease / diabetes / obesity / other relevant factors, or "None identified"]

Vaccination Status: [Influenza current season / COVID / RSV if age/risk eligible] (Include only vaccines relevant to this encounter.)

Allergies: [Relevant allergies or "Verified—denies"] (If unable to verify, state mitigation taken.)

Current Medications: [Key medications pertinent to antiviral interaction screening] (Required if prescribing antivirals; omit if not prescribing.)

Objective

Vitals: [Temperature, HR, RR, BP, SpO2 as available] (For telehealth, label patient-reported values explicitly.)

Exam: [General appearance, respiratory effort, auscultation findings, hydration status] (For telehealth, document observable findings and note exam limitations.)

Testing

Indication: [Diagnostic clarification / high-risk patient / exposure evaluation] | Day of illness at testing: [#]

• [Test name/type] — [Specimen type]; Result: [Detected / Not Detected / Invalid] (If results imported from lab interface: "Results reviewed in Labs.")
• (Add additional tests as needed.)

Interpretation: [Brief statement aligning results with clinical picture and timing] (For negative antigen results, address false-negative possibility and need for repeat/confirmatory testing. Note that positive result for one virus does not exclude co-infection.)

Assessment

• [Primary diagnosis]: [Confirmed infection per testing / Suspected viral syndrome; include risk stratification if it affects treatment]
• [Additional diagnoses affecting management]

Plan

• Antiviral therapy: [Drug, dose, duration] or [Not indicated—rationale] (Document eligibility based on risk and symptom timing; interaction screening performed and outcome; if COVID antiviral, note dose adjustments or alternative if needed.)

• Supportive care: [Antipyretics, hydration, rest, symptomatic therapies as discussed]

• Isolation guidance: Stay home until symptoms improving overall AND fever-free ≥24 hours without antipyretics; then added precautions (masking, hygiene, distancing) for 5 days. (Healthcare/employer/school rules may differ.)

• Return precautions: Seek care for new/worsening dyspnea, inability to speak full sentences, chest pain/pressure, confusion, persistent high fever, or dehydration signs. [Call clinic / return to urgent care / go to ED] for [timeframe and circumstances discussed].

• Orders: [Prescriptions / work-school note / repeat or confirmatory testing / follow-up plan] (Include only items ordered.)