Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit:
New diagnosis of Chlamydia trachomatis infection
Follow-up for previously diagnosed Chlamydia trachomatis infection
Evaluation for symptoms suggestive of Chlamydia trachomatis infection (e.g., pelvic pain, discharge)
SOAP
Subjective (S):
History of Present Illness:
For new diagnosis or follow-up:
Date of diagnosis or symptom onset (if applicable).
Presence of any symptoms (urethral discharge, dysuria, pelvic pain, testicular pain) – consider asking about these in a private setting.
Sexual history (number of partners, condom use).
For suspected diagnosis:
Inquire about symptoms suggestive of Chlamydia trachomatis infection (pelvic pain, abnormal vaginal discharge, burning with urination, testicular pain).
Sexual history (number of partners, condom use).
Past Medical History:
Briefly summarize relevant past medical history, including:
Previous sexually transmitted infections (STIs)
Underlying medical conditions
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Genital Exam (if indicated):
Perform a genital exam to assess for:
Urethral discharge (male) or vaginal discharge (female)
Cervical motion tenderness (female)
Pelvic tenderness (male or female)
Note: Genital exam may not be performed for all patients, use discretion based on symptoms and presentation.
Assessment (A):
Diagnosis:
Based on clinical presentation, sexual history, and test results (if available), diagnose:
Confirmed Chlamydia trachomatis infection (positive test)
Presumed Chlamydia trachomatis infection (suggestive symptoms and/or high-risk sexual behavior, awaiting test results)
Unlikely Chlamydia trachomatis infection (negative test and low risk factors)
Treatment Status (if applicable):
Document completion of treatment for a previously diagnosed infection.
Plan (P):
Testing (if not already performed):
Order a nucleic acid amplification test (NAAT) from urine or a swab of the cervix/urethra to diagnose Chlamydia trachomatis infection.
Treatment (if indicated):
If Chlamydia trachomatis infection is confirmed or presumed, prescribe a single-dose antibiotic regimen (e.g., azithromycin or doxycycline) for the patient and advise them to abstain from sexual contact until they and their partners complete treatment.
Provide partner notification services or encourage the patient to inform their sexual partners directly.
Follow-up:
Depending on the situation, consider:
Re-testing in 3 months to confirm treatment success (especially for pregnant women or those with high-risk factors).
Follow-up visit to address any persistent symptoms or complications.
Patient Education:
Educate the patient about Chlamydia trachomatis infection, transmission risks, importance of completing treatment, and the need to inform sexual partners.
Discuss safe sex practices (condom use) to prevent future infections.
Address any concerns about sexual health.
Additional Notes:
Document any other relevant information, such as:
Difficulty with partner notification or treatment adherence.
Consideration for expedited partner treatment.
Social determinants of health that may impact access to care or preventive measures.
Importance of returning for follow-up appointments as recommended.