Point-of-Care Testing Addendum (Respiratory, Urine, or Pregnancy)

Addendum to encounter dated: [original visit date]

Addendum date/time: [date and time of this addendum]

Author: [name, credentials]

Reason: Documenting POCT result(s) and management impact

Clinical Indication

[Symptom-based indication for testing and key timing] (Limit to 1–3 sentences supporting medical necessity. Do not restate the full HPI from the original note. If unclear from dictation, write "Indication not specified.")

Test and Results

(List each CLIA-waived POCT performed during this encounter. Duplicate the fields below for each test. Do not include QC logs, lot numbers, or expiration dates unless explicitly dictated.)

• Test performed: [test name]

  Specimen: [type and source] (If source not documented, write "specimen source not documented.")

  Collection date/time: [date and time] (If time unknown, document date only and note "time not recorded.")

  Result(s): [result exactly as reported] (Use native terminology: Positive/Negative/Detected/Not detected. For urinalysis, list pertinent dipstick findings.)

  Control validity: [Valid / Invalid] (Omit if not reported by the test.)

  Performed by: [name and role of operator] (Include only if performed by staff other than the documenting clinician.)

  Invalid/repeat attempts: [attempt number(s), outcome(s), and which result is used for clinical decision-making] (Include only if test was invalid and repeated.)

Interpretation and Management

[Clinical interpretation and management impact] (2–4 sentences addressing: 1) Interpretation of result(s) in clinical context. 2) Actions taken: medications started or deferred, additional testing ordered, disposition, follow-up plan. 3) Patient notification and key counseling provided. State explicitly that results were reviewed by the clinician. If results do not change management, state this clearly. If public health reporting applies, note "Reported per applicable requirements.")

Attestation: POCT result(s) reviewed; management updated as documented above.