Example_6_-_STD_Charting_Template.pdf
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- Attached to
- Electronic Health Records
- Solicitation number
- 2024-280
- Issued by
- Collin County, Texas
About this file
This document is a medical progress note from Collin County Health Care Services for a patient undergoing an STD screening and related medical examination. The progress note details a comprehensive physical examination covering multiple body systems, including eyes, ears, nose, mouth, throat, neck, lymphatic, skin, neurologic, and genitourinary areas. The patient presented with symptoms including eye pain, double vision, headaches, neck stiffness, and muscular weakness, and was diagnosed with STD exposure, Chlamydia, Gonorrhea, and early latent Syphilis.
The medical assessment includes multiple diagnostic tests and procedures, such as syphilis testing, blood collection, chlamydia and gonorrhea detection, and GC culture. The clinical plan involves partner notification, patient counseling about infection and prevention, referrals to primary care and immunization clinics, and specific treatment instructions. Recommendations include abstaining from sexual activity until partners are treated, following up for non-treponemal testing, obtaining vaccines, and taking specific medications like azithromycin and rocephin. The document also provides detailed post-treatment guidance, including avoiding alcohol and canned foods, using baking soda sitz baths, and maintaining treatment site cleanliness.
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Collin County Health Care Services Progress Note
Chie f Compla in t l STD Screening
Rev iew o f Sys tems
¡ Admits : eye pain, double vision, blurred vision, changes in vision
¡ Admits : headaches, neck stiffness, hearing loss, tinnitus
¡ Admits : muscular weakness
Phys ica l Examinat ion
¡ Appearance : well-nourished, well developed, alert and oriented X 3, in no apparent distress
¡ Vision : see nursing notes for visual acuity ¡ Conjunctivae : conjunctivae normal ¡ Sclerae : sclerae white ¡ Pupils and Irises : pupils equal and round, pupils reactive to light bilaterally, normal accommodation bilaterally ¡ Ophthalmoscopic Exam : retinas are normal without hemorrhage or exudate, lens clear, no papilledema present ¡ Corneas : tear film normal, no lesions present ¡ Intraocular Pressure : pressure O.D. normal, pressure O.S. normal ¡ Eyelids/Ocular Adnexae : eyelid appearance normal, no exudates present, eye moisture level normal ¡ Slit Lamp Exam : tear film normal; no lesions noted, anterior chambers clear bilaterally, no lens abnormalities noted
¡ Oral Cavity :
n Oral Mucosa : oral mucosa intact, no visable lesions n Lips : lip appearance normal, no visable lesions n Gums : gums pink, non-swollen, no bleeding present n Tongue : tongue appearance normal n Palate : hard palate normal, soft palate appearance normal
¡ Throat : no lesions, no patches, no erythema, no exudate
¡ Inspection/Palpation : normal appearance, no masses or tenderness, trachea midline ¡ Range of Motion : nuchal rigidity ¡ Jugular Veins : JVP less that 3 cm above sternal notch, waveform normal
¡ Abdominal Examination : abdomen nontender to palpation, tone normal without rigidity or guarding, no masses present
¡ Vagina : normal vaginal vault, no discharge present, no inflammatory lesions present, no masses present ¡ Uterus : nontender, smooth, mobile, no masses ¡ Adnexa : nontender, no palpable masses ¡ Anus : no inflammation or lesions present, no discharge present, no hemorrhoids present, no anal fissures present ¡ Perineum : perineum within normal limits
Patient Name: test test
Patient ID: 14252
Sex: Other
Birthdate: January 10, 1971
Create Date: November 4, 2024
Eyes
HENT
Musculoskeletal
Constitutional
Eyes
Ears, Nose, Mouth and Throat
Neck
Gastrointestinal
Genitourinary
[Date Printed:11/4/2024] Page 1 of 3[Progress Note] [test test] [14252]
[Digital Signature Validated]
¡ Neck : no lymphadenopathy present ¡ Axilla : no lymphadenopathy present ¡ Groin : no lymphadenopathy present ¡ Additional Nodes : no additional adenopathy present
¡ General Inspection : no rashes or lesions present, no areas of discoloration ¡ Body Hair : scalp palpation normal, hair normal for age, general body hair distribution normal for age
¡ Cranial Nerves : cranial nerves II - XII grossly intact ¡ Gait and Station : stable, coordination intact ¡ Cerebellar Function : cerebellar exam negative
Assessment l (1) STD Exposure V01.6 l (2) Chlamydia 099.50 l (3) Gonorrhea 098.0/A54.9 l (4) Syphilis - early latent 097.1
Plan
¡ Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART) (86592) - V01.6 - 11/04/2024 - Hold lab results until reviewed :No
¡ Collection of venous blood by venipuncture (36415) - - 11/04/2024 - Hold lab results until reviewed :No ¡ Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intramuscular (90471, 96372) - -
11/04/2024 - Hold lab results until reviewed :No ¡ Chlamydia and Neisseria gonorrhoeae detection by polymerase chain reaction (87591, 87491) - - 11/04/2024 - Hold lab results until reviewed :No ¡ GC culture (87081) - - 11/04/2024 - Hold lab results until reviewed :No
¡ ***Partner notification plan completed by provider/DIS.
¡ ***Partner notification plan refused by patient.
¡ ***Chlamydia / Gonorrhea ¡ ***Patient advised to notify partners in last 60 days (or most recent partner) and have seek treatment ASAP.
¡ ***Patient advised to return to clinic for rescreen in 3 months.
¡ ***Patient assessed for complications related to CT and GC prior to treatment, including exam if client reported signs/symptoms.
¡ ***Patient advised to abstain from sex for 7 days after single dose azithromycin (or until completion of doxycycline) CT treatment and/or GC treatment (including partners' treatment) ¡ ***HIV post-test counseling provided, with referral to their primary car provider / Health Services of North Texas in
Plano, TX.
¡ ***Patient was recommended to visit their primary care provider/HSNT for PrEP.
¡ ***Patient is offered Expedited Partner Therapy (EPT).
¡ ***Patient given printed information on Expedited Partner Therapy (EPT) in the partner's language ¡ ***Syphilis ¡ ***Patient completed RPR titer within a one week timeframe.
¡ ***Patient advised/refused to repeat RPR titer at initiation of syphilis treatment since last titer was more than one week old.
¡ ***Patient advised to abstain from sex for 7 days after single dose benzathine penicillin G treatment for early syphilis (including partners' treatment) ¡ ***Patient offered syphilis reverse algorithm serologic screening.
¡ ***Patient examined (skin, oral, genital, perianal), & assessed for signs/symptoms ocular/otic and neurosyphilis complications ¡ ***Patient referred for additional evaluation and treatment with specialists for positive ocular, otic, and/or neurosyphilis findings
Lymphatic
Skin and Subcutaneous Tissue
Neurologic
Orders
Instructions
[Date Printed:11/4/2024] Page 2 of 3[Progress Note] [test test] [14252]
¡ ***Patient was recommended to visit their primary care provider/HSNT for PrEP.
¡ ***Patient advised to follow up for non-treponemal testing ¡ HIV pre-test counseling provided.
¡ ***HIV post-test counseling provided, with referral to their primary car provider / Health Services of North Texas in
Plano, TX.
¡ Patient counseled about infection, treatment, and prevention.
¡ Abstain from sex until all partners are treated and 7 days post treatment.
¡ Referred to immunization clinic for HPV, Hep B, Influenza, and Jynneos vaccines.
¡ Referral provided.
¡ Consulted with Dr. Nishat.
¡ Syphilis and STD literature provided per Centers for Disease Control (CDC) guidelines.
¡ Medication(s) instructions provided (azithromycin, rocephin, metronidazole, valtrex, doxycycline).
¡ Medication: Bicillin information provided. Discussed Jarisch-herxheimer reaction symptoms and management.
¡ Discussed results and prevention of STD's.
¡ Provided condoms and instructed to use at all times for safe sexual practices.
¡ No alcohol intake, avoid canned foods and canned drinks the day of treatment and two more days after completion of treatment.
¡ Recommended baking soda sitz bath twice a day until symptoms improve.
¡ Recommended Pap Smear as soon as possible, low cost clinic information given.
¡ Keep treatment site clean and dry for 10 days. Call or return to clinic if signs/symptoms occur.
¡ Call 972-548-5529 for test results on: ____________________.
¡ Patient observed for 20 minutes post injection.
¡ Call or Return if symptoms worsen or persist.
Electronically Signed by: Ramzi Taim, -Author on November 4, 2024 11:17:16 AM
Disposition
[Date Printed:11/4/2024] Page 3 of 3[Progress Note] [test test] [14252]
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