PrEP Follow-up/Injection Visit Note

Date/Time: [Date and time]

Visit Type: [PrEP follow-up / CAB injection visit / Oral PrEP refill]

PrEP Modality: [Injectable CAB / Oral TDF-FTC / Oral TAF-FTC] (Note if restart after lapse.)

Provider: [Name, credentials]

Reason for Visit

[One-line purpose of visit]

Interval History

[Brief narrative since last visit covering: interval HIV exposure risk and partner context in nonjudgmental language; adherence/persistence (missed oral doses or CAB injection attendance); explicit presence or absence of acute HIV symptoms (fever, fatigue, pharyngitis, rash, lymphadenopathy, myalgias) with timing if present; medication tolerance and side effects (include injection site reactions for CAB if applicable); any STI symptoms (discharge, dysuria, rectal symptoms, pharyngitis, sores).] (Do not substitute a generic ROS; explicitly document acute HIV symptom presence/absence. If exposure details are declined, neutrally document refusal and how testing decisions were made.)

Objective

Vitals: [Vitals if obtained; include weight when relevant to dosing] (Omit line if not collected.)

Exam: [Pertinent findings only; include injection site assessment if prior issues and targeted STI exam if symptomatic] (Omit line if no exam performed.)

Labs collected today: [HIV testing with test type (Ag/Ab 4th gen, HIV-1 RNA) and result/pending status; STI NAAT by anatomic site collected (urine, rectal, pharyngeal); syphilis serology; pregnancy test if indicated; renal function if due for oral tenofovir-based PrEP] (Document reason and plan if required labs not obtained.)

Results reviewed: [Recent HIV test results with dates; STI results by site; other relevant labs]

CAB Injection

(Include this section only if an injection was administered or attempted.)

Medication: Cabotegravir LA [dose in mg/mL]

Route/Site: IM, [ventrogluteal / dorsogluteal], [L / R]

Time administered: [Time]

Administered by: [Name, role]

Lot/Exp: [Per local policy]

Injection phase: [Initiation dose 1 / Initiation dose 2 / Continuation]

Window status: [On schedule / Late by X weeks]

Tolerance: [Tolerated well / Immediate reaction noted: describe]

Injection not given: [Reason] (Include only if deferred; e.g., HIV testing not confirmed negative, patient declined, clinical concern for acute HIV.)

Assessment and Plan

1. HIV Prevention / PrEP

[Current PrEP modality and appropriateness; adherence/persistence summary; explicit acute HIV symptom assessment summary.]

HIV testing status: [Test type, result or pending, date] (Explicitly document to support CAB safety requirements.)

Proceeding with PrEP: [Yes / No] (If results pending and continuing, document clinical rationale. If holding due to concerning results or symptoms, document confirmatory testing plan.)

CAB-specific: [Injection given / deferred with rationale; next injection due date and window; tail-period counseling and bridging plan if late or discontinuing] (Include only for CAB patients.)

Oral PrEP-specific: [Refill quantity aligned with next HIV test; renal monitoring interval] (Include only for oral PrEP patients.)

2. STI Screening/Treatment

Tests ordered: [Anatomic sites and rationale based on exposure/symptoms]

Treatment provided: [Medication, dose, route; partner management plan] (Include only if treatment indicated.)

Doxy-PEP: [Offered / Discussed / Declined / Not applicable] (Per local policy.)

3. Other

[Vaccinations addressed (HepA/B, HPV, Mpox); reproductive health if relevant; other active issues addressed today] (Omit section if none applicable.)

Follow-Up

Next visit: [Date and type: injection visit / lab-only / clinician follow-up]

Next HIV testing due: [Date]

Next STI screening due: [Date]

Return precautions: Instructed to return sooner for acute HIV symptoms (fever, rash, sore throat, fatigue), severe injection site reaction, or new STI symptoms.