Vaginitis/STI Evaluation Note

Date/Time: [Date and time]

Author: [Name, credentials]

Encounter type: [in-person / telehealth / urgent care / ED]

Chaperone: [present (name/role) / declined by patient / N/A (no pelvic exam)]

Subjective

Chief Concern: [Patient-stated presenting symptom(s)]

HPI: [Narrative history of present illness] (Include discharge characteristics—onset, duration, color, consistency, odor; associated symptoms—itching, burning, dysuria, dyspareunia, pelvic pain; gynecologic context—LMP, pregnancy possibility; exposure history—new partners, partner symptoms, condom use; self-treatment attempts; and red flags—fever, severe pain, genital ulcers. Omit elements not discussed.)

Sexual History: [5 Ps summary: partners, practices, protection, past STIs, pregnancy intention] (Include only when STI evaluation is clinically indicated. Keep brief and relevant to testing decisions and partner management. Omit section if not applicable.)

Pertinent History: [Prior STIs/PID, IUD/contraception status, relevant comorbidities, current medications affecting differential, drug allergies to azoles/nitroimidazoles/beta-lactams] (Include only items relevant to the current problem.)

Objective

Vitals: [Temperature required; other vitals as relevant]

Exam: [Abdomen—suprapubic tenderness; external genitalia—erythema, lesions, discharge; speculum—vaginal walls, discharge description, cervical appearance including mucopus or friability; bimanual—cervical motion tenderness, uterine tenderness, adnexal tenderness] (If pelvic exam deferred, document reason and alternative approach. Include pertinent positives and negatives.)

POC Testing: [Vaginal pH, whiff test, wet mount findings with specimen source] (Note if wet mount read immediately. Include urine pregnancy test when relevant to management.)

Labs Sent: [Pending tests with specimen sites] (Include plan for result notification: method and expected timeframe.)

Assessment

[Problem-oriented list with status tags] (For each diagnosis, include status in parentheses: confirmed, probable, suspected, or ruled out. Provide brief supporting findings. Address vaginitis etiology versus cervicitis/STI. Explicitly document PID consideration when pelvic pain present or cervical motion/uterine/adnexal tenderness found.)

Plan

[Organized by problem] (For each problem include: treatment with dose/route/duration and whether empiric or pathogen-directed with rationale; partner management when STI diagnosed or suspected—notification timeframe, abstinence guidance, EPT if applicable; follow-up—results communication method, return precautions for fever/worsening pain/no improvement, retesting plan ~3 months for GC/CT/trich when treated. For vaginitis without STI concern, partner treatment generally not indicated; document counseling if patient inquires. Ensure regimen is pregnancy-appropriate; if pregnancy status unknown and relevant, document how addressed.)