Please write a SOAP note for a routine tuberculin skin test (PPD) read at 48‑72 hours with 0 mm induration (negative) in an asymptomatic adult without prior TB exposure or immunosuppression.

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SOAP Note for Negative Tuberculin Skin Test Reading

Subjective

  • Patient presents for tuberculin skin test (TST) reading, placed [X] hours ago
  • No symptoms of active tuberculosis (no cough, fever, night sweats, weight loss, hemoptysis)
  • No known recent TB exposure
  • No history of prior positive TST
  • [Document BCG vaccination history if applicable]
  • [Document risk factors: HIV status, immunosuppression, country of origin, occupation, congregate settings]

Objective

  • TST reading performed at 48-72 hours post-placement 1, 2
  • Induration measured by palpation: 0 mm (transverse diameter)
  • Erythema only, if present, is not considered in interpretation 3
  • No vesiculation or ulceration noted
  • Vital signs: [if obtained]
  • General appearance: Well-appearing, no acute distress

Assessment

Negative tuberculin skin test (0 mm induration)

The interpretation of this negative result depends critically on the patient's risk stratification 1, 2:

  • For patients requiring ≥5 mm cutoff (HIV+, recent TB contact, prior TB on chest X-ray, TNF-blocker therapy): This is a negative result, but consider false-negative if immunosuppressed 1, 4
  • For patients requiring ≥10 mm cutoff (recent immigrants from high-prevalence countries, injection drug users, healthcare workers, residents of congregate settings): This is a negative result
  • For patients requiring ≥15 mm cutoff (no risk factors): This is a negative result

Important caveats for false-negative results 1, 4:

  • False-negatives occur more frequently in: HIV infection (strongest association, aOR 4.65-5.05), chronic renal failure, alcohol/drug abuse, age ≥65 years, early infection (<6-8 weeks post-exposure), recent viral vaccination, overwhelming TB disease, high-dose corticosteroids, TNF inhibitors
  • If clinical suspicion remains high despite negative TST, consider repeat testing in 1-2 weeks (booster phenomenon) or interferon-gamma release assay (IGRA)

Plan

  1. No treatment indicated for latent TB infection given negative result
  2. Document result as 0 mm induration at [48-72] hours
  3. If high-risk exposure or immunosuppression: Consider repeat TST in 8-10 weeks if recent exposure, or IGRA testing if immunosuppressed 1
  4. Patient education: Explained negative result means no evidence of TB infection at this time; advised to report any TB symptoms (persistent cough >3 weeks, fever, night sweats, weight loss)
  5. Follow-up: Routine unless symptoms develop or new TB exposure occurs
  6. For occupational health: Document for annual screening records; next TST per facility protocol (typically annual for healthcare workers)

Note on technique verification: TST was properly administered via Mantoux method (0.1 mL of 5 TU PPD intradermally) with documented wheal formation at placement 2, 3. Reading performed by trained personnel measuring transverse diameter of induration, not erythema 1, 2.

References

3
Research

Tuberculin testing: placement and interpretation.

AAOHN journal : official journal of the American Association of Occupational Health Nurses, 1995

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