An urgent care note records one walk-in visit: the complaint, a focused history and exam, the tests done on site, your decision making, and where the patient goes next. Copy the free template, see an ankle injury sent home and a chest pain transferred by ambulance, and check what goes in each part.
Blank urgent care note template
FreeURGENT CARE NOTE Patient: [Name, age, sex] Date of birth: [Date] Date of visit: [Date] Arrived: [Time of arrival, and time first seen by a clinician] Arrived by: [Walk-in, booked online, brought by family, or sent by another clinician] Triage: [Triage level or category, and any concern the triage nurse flagged] Primary care clinician: [Name, or none] Clinician: [Name, credentials] CHIEF COMPLAINT [The reason for the visit in the patient's words, and how long it has been going on] HISTORY History of present illness: [Onset, mechanism or trigger, location, character, severity, what makes it better or worse, and what was tried before coming in] Pertinent review of systems: [The positives and negatives that bear on this complaint and its red flags] Relevant history: [Past medical, surgical, and social history that matters today; pregnancy status, last tetanus shot, or recent travel when relevant] Medications: [Current medications, and anything taken today for this problem] Allergies: [Drug and other allergies, with reactions] VITAL SIGNS AND EXAMINATION Vital signs: [BP, HR, RR, temperature, SpO2, pain score, with the time taken] Repeat vital signs: [Time and values, when any were abnormal or treatment was given] General: [How unwell the patient looks, distress, gait] Focused exam: [Findings for the complaint, and for the serious causes you are ruling out] POINT-OF-CARE TESTS AND IMAGING Done on site: [Rapid strep, urinalysis, pregnancy test, glucose, ECG, X-ray, or other, with times] Results: [Each result with your read; who read the imaging, and whether a radiologist report is still to come] MEDICAL DECISION MAKING Differential: [Diagnoses considered, and why each is more or less likely] Red flags: [Serious causes considered, and the findings that exclude them or don't] Decision rules: [Rule used by name, the findings that decided it, and the result] Diagnosis: [Final or working diagnosis] TREATMENT Given in clinic: [Medication, dose, route, and time; procedures such as splinting, wound repair, or a nebulizer; and the response] Prescriptions: [Drug, dose, frequency, duration, and quantity, or none] Advice: [What was explained, and the patient's understanding and agreement] DISPOSITION Disposition: [Home, home with follow-up, or transfer to the emergency department] Follow-up: [With whom and when; who will act on results still to come] Transfer: [Receiving site, how the patient traveled, time of departure, who handed over to whom and when, and what was sent] Condition on leaving: [Stable or improved, with the last vital signs] RETURN PRECAUTIONS [The specific signs that mean come back or go to the emergency department, and that the patient understood them] WORK OR SCHOOL NOTE [Given or not; dates off, return date, or limits on duties] Signed: [Clinician name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Urgent care clinic, evening walk-in
Arrived 7:52 p.m., walk-in; seen 8:10 p.m. Triage: less urgent, no concerns flagged. 24-year-old man. “I rolled my ankle playing basketball and it’s swollen.” 90 minutes. Primary care clinician: Dr. Amy Lin.
Landed on another player’s foot at 6:30 p.m. and rolled his right ankle inward. Felt a pop on the outside of the ankle and stopped playing. Swelling within 30 minutes. Walked to his car with a limp. Iced it at home; no medicine taken. No numbness or tingling, no knee or foot pain, no previous injury to this ankle. Healthy, no regular medications, no stomach ulcers or kidney disease. No known drug allergies. Works as a line cook, on his feet for 10-hour shifts.
At 8:10 p.m.: BP 128/76, HR 78, RR 14, T 36.9 °C (98.4 °F), SpO2 99% on room air, pain 6 out of 10. Comfortable at rest; walks with a limp. Right ankle: swelling and early bruising over the outer ankle. Tender over the anterior talofibular ligament and at the tip of the lateral malleolus. Not tender over the medial malleolus, the navicular, the base of the fifth metatarsal, or the proximal fibula. Syndesmosis squeeze test negative. Thompson test normal. Anterior drawer not tested: too painful and swollen; recheck at 4 to 5 days. Foot pulses strong, capillary refill under 2 seconds, sensation normal across the foot. Took 4 steps without help, limping.
Right ankle X-ray at 8:24 p.m., 3 views: AP, lateral, and mortise. No fracture; mortise even; soft tissue swelling on the lateral side. Read by me; radiologist report to follow tomorrow. Foot X-ray not needed.
Ottawa ankle rules: ankle X-ray indicated, on bone tenderness at the tip of the lateral malleolus. Foot rules negative: no navicular or fifth metatarsal tenderness, and able to bear weight. Differential: lateral ankle sprain, distal fibula fracture, high ankle sprain, fifth metatarsal fracture, Achilles rupture. X-ray shows no fracture. Negative squeeze test and no proximal fibula tenderness make a high ankle sprain unlikely; Thompson test rules out an Achilles rupture. Foot circulation and nerves intact. Diagnosis: right lateral ankle sprain, most likely the anterior talofibular ligament.
Ibuprofen 400 mg by mouth at 8:35 p.m. Ice and elevation in the clinic. Semi-rigid lace-up brace fitted. Crutches given and gait taught; weight bearing as tolerated, off crutches over 2 to 3 days. No prescriptions: ibuprofen 400 mg up to 3 times a day with food for up to 7 days, and acetaminophen as needed, both over the counter. Advice: ice for 15 to 20 minutes every 2 to 3 hours for 2 days, and keep it raised; start ankle circles and tracing the alphabet with his foot tomorrow; walk as pain allows. Wear the brace for basketball when he goes back. He understood and agreed.
Home. Follow up with Dr. Lin in 5 to 7 days to recheck the ligament; referral to physical therapy then if he isn’t walking normally. The clinic will call him if the radiologist report differs from my read. Left at 8:55 p.m. on crutches, pain 3 out of 10.
Return, or go to the emergency department, for numb, cold, or pale toes; pain that keeps getting worse despite rest, ice, and raising the leg; a tight, swollen calf; or still no weight on the foot after 5 days. Printed copy given; he repeated them back. Work note given: off work Nov 10 and 11; back Nov 12 in the brace, with seated breaks as needed for 1 week.
Urgent care clinic, morning walk-in, transferred by ambulance
Arrived 9:58 a.m., walk-in, driven by her husband. Triage nurse took her straight to a room and called me; seen 10:00 a.m. 58-year-old woman. “There’s a weight on my chest and it won’t go away.” 40 minutes. Primary care clinician: Dr. Marcus Reid.
Central chest pressure began at 9:20 a.m. while climbing the stairs from the train platform, and was still there after 30 minutes of rest. Spreads to the left arm and jaw. Sweaty, nauseated, and a little short of breath. 7 out of 10. Not sharp, not worse with breathing or position, not tearing, no back pain. No palpitations, fainting, cough, or leg swelling; no recent surgery, long travel, or coughing blood. Brief tightness on stairs twice last week, gone within 2 minutes. History: high blood pressure, type 2 diabetes, high cholesterol; smokes 10 cigarettes a day. Father had a heart attack at 61. Medications: metformin 1,000 mg twice daily, ramipril 10 mg daily, atorvastatin 40 mg daily; no anticoagulants or sildenafil-type medicines; no aspirin today. No known drug allergies; no bleeding problems or stomach ulcers.
At 10:01 a.m.: BP 162/94 right arm, 158/92 left arm, HR 102 regular, RR 20, SpO2 96% on room air, T 36.8 °C (98.2 °F), pain 7 out of 10. Pale, sweaty, and anxious; speaking in full sentences. Heart sounds normal, no murmur or rub. Chest clear, air entry equal on both sides. Radial pulses equal. No calf swelling or tenderness. Abdomen soft, not tender. Speech and limb movements normal. Repeat at 10:20 a.m., after nitroglycerin: BP 138/84, HR 94, SpO2 97%, pain 3 out of 10.
ECG at 10:04 a.m., 6 minutes after arrival: sinus tachycardia at 104, horizontal ST depression of 1 mm in V4 to V6, no ST elevation in any lead. No old ECG on file to compare. Repeat ECG at 10:18 a.m.: rate 96, ST depression unchanged. Fingerstick glucose 176 mg/dL (9.8 mmol/L). No troponin testing on site.
Acute coronary syndrome most likely: 40 minutes of pressure on exertion, spreading to the arm and jaw, with sweating, new ST depression, and several risk factors. No ST elevation, so no STEMI criteria met. Aortic dissection unlikely: no tearing or back pain, arm pressures within 4 mmHg, pulses equal, no murmur, no neurological signs. Pulmonary embolism less likely: no leg signs, recent surgery, travel, or coughing blood; PERC can’t rule it out at age 58. No signs of a pneumothorax or pericarditis. No decision rule supports sending her home without serial troponins; ongoing pain with ischemic ECG changes needs the emergency department. Diagnosis: suspected acute coronary syndrome, likely non-ST-elevation.
911 called at 10:06 a.m. Aspirin 325 mg chewed at 10:07 a.m. Nitroglycerin 0.4 mg under the tongue at 10:10 a.m., with BP 162/94; pain 4 out of 10 and BP 144/86 at 10:15 a.m., so a second dose then. Oxygen not given: SpO2 96%. Cardiac monitor and defibrillator pads on; IV cannula in the left forearm; a nurse stayed with her throughout. No prescriptions.
Transfer by ambulance to the emergency department at Riverside General. She first asked her husband to drive her; I explained the risk of a dangerous heart rhythm on the way, and she agreed to the ambulance. Paramedics arrived 10:19 a.m. Face-to-face handover to the crew lead at 10:22 a.m.: suspected non-ST-elevation acute coronary syndrome, onset 9:20 a.m., aspirin 325 mg at 10:07 a.m., nitroglycerin 0.4 mg at 10:10 and 10:15 a.m., latest vital signs, no allergies. Sent with her: both ECGs, this note, and her medication list. Phoned Dr. Sara Okafor, emergency physician at Riverside General, at 10:26 a.m. with the same summary. Left at 10:29 a.m. on the monitor: BP 138/84, HR 94, SpO2 97%, pain 3 out of 10. Husband following by car. Copy of this note to Dr. Reid.
Not applicable: care handed over to the emergency department. No work note today; the hospital team will give one if needed.
When and how the patient came in, and why, in their words. The times show how quickly a sick patient was seen.
Avoid: A complaint rewritten as a diagnosis. “Ankle sprain” at triage anchors everyone who reads it; “rolled right ankle playing basketball” doesn’t.
A focused history: enough to make today’s decision, and to show the serious causes you asked about.
Avoid: A full review of systems ticked as negative. Ask about, and record, the negatives that matter for this complaint.
A full set of vital signs, and an exam focused on the complaint and on what could make it dangerous.
Avoid: Sending a patient home with a fast heart rate or low oxygen level that was never rechecked. Repeat it, and write the repeat.
The tests done on site, with their results and who read them.
Avoid: “X-ray negative” with no views and no reader. Name the views, who read them, and what happens if the radiologist’s report differs.
Your reasoning: what you considered, what you ruled out and how, and why the patient can go home or must go elsewhere.
Avoid: A rule named with no findings. “Ottawa negative” doesn’t show which criteria you checked. Write the findings that decided it.
What you gave in the clinic, what you prescribed, and what you explained.
Avoid: Leaving out the time a medicine was given. If the patient moves on, the next team needs to know what is already on board, and since when.
Where the patient went next, and who is responsible for them now.
Avoid: “Sent to ED” and nothing else. Record how the patient went, who you spoke to, and what went with them.
The signs that should bring the patient back, specific to the diagnosis, and any note for work or school.
Avoid: “Return if worse.” Name the signs that matter for this diagnosis, such as numb toes after a sprain or a stiff neck with a fever.
If you considered a fracture, a dissection, or meningitis and ruled it out, write how. Without that, the note reads as if you never thought of it.
Many clinics read their own X-rays and get a formal report later. Note that one is still to come, and who calls the patient if it differs from your read.
Write when you called for transport, how the patient traveled, who you handed over to and when, and what went with them. Gaps here are where care gets lost.
If the patient won’t go to the emergency department, record their capacity, the risks you explained in plain words, what they agreed to instead, and that they can come back or call 911 at any time.
A heart rate of 118 at triage needs a recheck after fever control or fluids. Write the repeat values before the patient leaves.
Vero Scribe writes the urgent care note in your template from the visit, with the patient’s consent, or from your dictation. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
The arrival time and chief complaint, a focused history with the red flags you asked about, vital signs and a focused exam, tests done on site with results, your medical decision making, treatment given and prescribed, the disposition, return precautions, and any work or school note.
It follows the same order, from history to plan, and adds what a one-time walk-in visit needs: arrival times, on-site tests and who read them, the red flags and decision rules behind your decision, and a disposition for discharge, follow-up with the patient’s own clinician, or transfer. Most patients won’t see you again, so the note has to stand on its own.
Write why the patient needs the emergency department, what you gave and when, when you called for transport and how the patient traveled, who you handed over to and when, the receiving site, and what went with the patient, such as ECGs and results. Record their condition and vital signs when they left. If they declined an ambulance, record the risks you explained and what they agreed to.
The Ottawa ankle and knee rules for X-rays after injury, the Centor or McIsaac score for sore throat, NEXUS for neck injury, PECARN for head injury in children, and Wells and PERC for a suspected clot in the lungs. Name the rule, the findings, and the result, and note when a rule can’t settle the question, as with PERC in a patient aged 50 or over.
Yes. Copy it, or download it as a Word or text file. No account needed.
Walk-in visit notes, drafted from the visit for your review.
Notes for the emergency department, where your transfers arrive.
The work or school note: dates off, return date, and limits.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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