Point-of-Care Strep Test Encounter Note

Date of Service: [Date of Service]

Patient: [Patient name or identifier]

Provider: [Provider name and credentials]

Setting: [Clinic / Urgent Care]

Chief Complaint

[Chief complaint] (Brief patient statement; include direct quote only if it adds clarity.)

History of Present Illness

[Acute pharyngitis illness narrative] (Concise paragraph covering onset and duration of sore throat; fever history with highest measured temperature; severity and functional impact on swallowing and oral intake; presence or absence of cough—document explicitly; URI features such as rhinorrhea or congestion; known strep exposure; and any prior treatments. Integrate Centor-like clinical features naturally: fever above 38°C, absence of cough, tonsillar exudate or swelling, and tender anterior cervical lymphadenopathy. If overt viral features are present but testing was performed, briefly note rationale.)

[Allergies relevant to antibiotic selection] (List drug allergies with reaction type. If allergy status cannot be confirmed, explicitly state this.)

[Relevant past medical history] (Include only if it affects management: history of rheumatic fever, immunocompromise, or recurrent strep infections.)

Objective

Vitals: [Temperature and route, HR, RR, BP, SpO2, weight if pediatric] (Include only values obtained.)

Exam: [General appearance and hydration]; [Oropharynx: erythema, tonsillar size, exudate, palatal petechiae, uvula position]; [Anterior cervical lymphadenopathy]; [Pertinent negatives]

POC Strep Test: [Test type: rapid antigen / molecular]; Result: [Positive / Negative / Invalid]; [Brief interpretation contextualizing result] (If invalid, note whether test was repeated.)

Assessment

[Primary diagnosis with POC test result context] (For positive test: confirmed GAS pharyngitis. For negative test with viral features: viral pharyngitis, GAS unlikely. For negative test in child with culture pending: note diagnostic uncertainty.)

[Secondary diagnoses if clinically meaningful]

Plan

(Include only the pathway matching the assessment.)

• If confirmed GAS pharyngitis: [Antibiotic regimen with dose, frequency, duration; use weight-based dosing for pediatrics]; [Symptomatic care]; Return to school/work when afebrile and ≥12-24 hours on antibiotics; [Return precautions for worsening: difficulty breathing/swallowing, unilateral swelling, persistent fever, no improvement in 48-72 hours]

• If negative POC in child/adolescent: Throat culture sent [Yes / No]; [Result communication method and expected turnaround]; Start antibiotics only if culture positive; [Supportive care]; [Return precautions]

• If negative POC with viral syndrome: No antibiotics indicated; [Supportive care]; Return to school/work when afebrile and improving; [Return precautions]

• If empiric antibiotics without confirmatory testing: [Document specific clinical rationale]; [Antibiotic regimen]; Reassess in 48-72 hours

[Safety documentation] (If weight, allergy status, or other critical information is missing, document the gap and how it was addressed.)

[Follow-up plan and disposition]