What is a sample documentation for a patient presenting with throat issues?

Sample Documentation for Throat Infection

Proper documentation of throat infections requires recording specific clinical features at each episode: temperature >38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive testing for group A beta-hemolytic streptococcus, along with the date and presence of sore throat. 1

Essential Documentation Elements for Each Episode

Subjective Findings

• Date of visit and chief complaint of sore throat 1
• Duration and severity of throat pain 1
• Associated symptoms: fever (document actual temperature), difficulty swallowing, voice changes 1
• Absence from school or work due to the episode 1
• Spread of infection within family members 1

Objective Clinical Features (Document Presence or Absence)

• Temperature: Record if >38.3°C (101°F) 1
• Cervical lymphadenopathy: Note if tender nodes present or nodes >2 cm 1
• Tonsillar exudate: Document presence or absence 1, 2
• Pharyngeal or tonsillar erythema 1
• Tonsil size (if enlarged) 1

Laboratory Documentation

• Microbiologic test results: Rapid strep test or throat culture for group A beta-hemolytic streptococcus 1, 2
• Document if test was positive or negative 1

Sample Documentation Template

Example 1 (Episode Meeting Criteria): "3/15/2024: Patient presents with sore throat x 2 days. Temperature 38.8°C. Examination reveals bilateral tonsillar exudate, erythematous pharynx, and tender anterior cervical lymphadenopathy. Rapid strep test positive for group A beta-hemolytic streptococcus. Prescribed amoxicillin. Missed 2 days of school." 1, 2

Example 2 (Episode Not Meeting Criteria): "4/20/2024: Patient reports sore throat x 1 day. Temperature 37.2°C. Examination shows mild pharyngeal erythema, no exudate, no adenopathy. Rapid strep test negative. Likely viral pharyngitis. Advised supportive care and hydration." 1, 2

Critical Documentation Pitfalls to Avoid

• Never document "recurrent sore throats" without specific episode counts and dates - this vague documentation cannot be used to determine tonsillectomy eligibility 1
• Do not rely on patient recall alone - contemporaneous notation in the clinical record at the time of each episode is required 1
• Avoid documenting only antibiotic prescriptions without the qualifying clinical features (fever, adenopathy, exudate, or positive test) 1
• Do not count episodes treated at outside facilities unless you obtain and review their documentation with the required clinical features 1

Documentation for Tonsillectomy Consideration

For patients potentially meeting surgical criteria, maintain a running count of documented episodes over time with the Paradise criteria features 1:

• Track episodes over 12 months (for ≥7 episodes), 24 months (for ≥5 per year), or 36 months (for ≥3 per year) 1
• Each counted episode must have sore throat PLUS at least one qualifying feature documented 1
• Note whether antibiotics were prescribed for suspected or confirmed streptococcal episodes 1

If documentation is incomplete but history suggests severe recurrent infections, prospectively document the pattern in 2 subsequent episodes before considering surgery 1. This allows patients with inadequate prior documentation to still qualify if the same pattern continues and is properly recorded 1.