Patient: [Patient Name]
Date: [Date of Encounter]
I. Chief Complaint:
Fever (temperature)
Cough (productive or non-productive)
Shortness of breath (dyspnea)
Fatigue
Loss of taste or smell (anosmia/dysgeusia)
Other symptoms (muscle aches, headache, sore throat, diarrhea)
II. History of Present Illness:
Onset and duration of symptoms
Severity and progression of symptoms
Potential exposures to COVID-19 (contact with confirmed case, travel history)
Vaccination status (including number of doses, booster received)
III. Past Medical History:
Underlying medical conditions (chronic lung disease, heart disease, diabetes, immunocompromise)
Previous hospitalizations for respiratory illness
IV. Medications:
Current medications
V. Social History:
Occupation (increased risk of exposure)
Household contacts (potential exposure risk)
VI. Vital Signs:
Blood pressure (BP)
Heart rate (HR)
Respiratory rate (RR)
Oxygen saturation (SpO2) – assess on room air and with supplemental oxygen if applicable
Temperature
VII. Physical Exam:
General appearance (illness severity)
Respiratory exam:
Rate and depth of respirations
Use of accessory muscles
Chest auscultation (rales, wheezing)
VIII. Diagnostic Studies (consider as appropriate):
Viral testing:
RT-PCR nasopharyngeal swab for confirmation of COVID-19 infection
Chest X-ray or CT scan: may be indicated for patients with concerning symptoms (severe shortness of breath, suspected pneumonia)
IX. Assessment:
Confirmed or suspected COVID-19 infection based on clinical presentation, exposure history, and testing results (if available)
Severity of illness (asymptomatic, mild, moderate, severe) – consider using a standardized tool like WHO Clinical Progression Scale for COVID-19
Risk factors for complications (age, underlying medical conditions)
X. Plan:
Treatment depends on severity of illness:
Mild illness (outpatient management):
Supportive care (rest, hydration, fever management)
Monitor for symptom worsening
Isolation recommendations (to prevent spread)
Moderate illness:
Consider oral medications (antivirals) – if appropriate for the patient
Supplemental oxygen therapy (if oxygen saturation falls below specific threshold)
Close monitoring
Severe illness (hospitalization):
Advanced respiratory support (mechanical ventilation)
Other supportive measures (fluids, medications)
Vaccination (if not already vaccinated and not contraindicated) should be discussed for future protection.
XI. Prognosis:
Discuss the expected course of illness for most patients (improvement within 1-2 weeks).
Advise on isolation precautions and monitoring for worsening symptoms.
Address the patient’s anxieties and concerns related to COVID-19.
XII. Notes:
Include any additional observations or concerns, such as patient’s understanding of the diagnosis, isolation recommendations, medication adherence, and need for follow-up.
XIII. Resources:
Consider providing patient education materials on COVID-19 from reputable sources (e.g., Centers for Disease Control and Prevention (CDC), World Health Organization (WHO)).