Concise Urgent Care Visit

Chief Complaint

Medical Note Template -- Urgent Care Visit

HPI

[Provide a detailed history of present illness including symptom duration, character, associated symptoms, relevant negatives, recent changes in exposures or habits, and any other pertinent information. For example, include details about symptom onset, severity, and any relevant lifestyle or medical history factors. Put relevant negative all at the end of HPI.] [Put past medical history here with associated medicine used]

Social History

Alcohol consumption status: [e.g., never, occasional, daily] Current smoking status: [e.g., never smoker, former smoker, current smoker] Recreational drugs: [e.g., none, type and frequency if applicable]

Past Medical History

Past Surgical History

Current Medications

Allergies

Test Results

Diagnosis

[List the diagnosis or diagnoses relevant to the visit, including ICD codes. For example: (ICD code: diagnosis)]

Treatment Plan

Today we discussed the following: [Do not use complete sentences, be concise but clear. Medical abbreviations are encouraged] 1. [Acute problem or diagnosis] - [If vitals are discussed: put ''VSS'' if vitals are normal, if vitals are abnormal (such as tachycardia or fever, list that here)]. - Exam: [document significant exam findings if discussed by provider such as erythematous oropharynx or LLQ tenderness. No not put subjective complaints of the patient here]. - [Document significant test results such as urinalysis findings, cultures sent, imaging, etc. If no tests were talked about, remove this line] - [if differential diagnosis is discussed list it here following DDx:] [if differential is not included please skip this line] - [List prescribed medications and discuss potential adverse drug reactions with instruction on how to use. Make this part concise, do not use.] - [Describe patient education provided, such as advice on hydration, over-the-counter medications for symptom relief, lifestyle modifications. Make this part concise.] - Red flags discussed: Instructed to go to the Emergency Department if experiencing acutely worsening symptoms such as [insert other return to clinic or red flag symptoms here] - RTC if symptoms do not improve or resolve [also put return to clinic precautions here that were discuss that do not warrant emergency department visit]. 2. [Acute problem or diagnosis only if multiple problems/diagnosis] - [List prescribed medications for this complaint and discuss potential adverse drug reactions with instruction on how to use. Make this part concise, do not use.] - [List education given to patient regarding this symptoms, including follow-up if discussed] 3. [Chronic illness if patient has past medical history listed in HPI. If they deny all past medical history, skip this part] - Continue [medication] as outlined by PCP