URGENT 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]