WALK-IN CLINIC TEMPLATE

Chief Complaint

[Insert chief complaint: Patient presents with…]

History of Present Illness (HPI)

[Provide a detailed narrative of the history of present illness, including onset, duration, progression, associated symptoms, and relevant negatives. Summarize pertinent positives and negatives from the Review of Systems. Do not include unrelated symptoms. Use full sentences.]

Past Medical History (PMH)

[List relevant past medical history, including chronic illnesses, previous hospitalizations, and surgeries. Use bullet points or full sentences as appropriate.]

Social History (SHx)

Smoking: [Never / Former / Current — packs/day, years] Alcohol:[None / Social / Heavy — frequency and amount] Drugs:[Cannabis, recreational drugs, IV drug use] Living Situation:[Lives alone / with family / housing concerns] Occupation: [Insert occupation] Recent travel:[Insert recent travel history]

Review of Systems (ROS)

[List only positive findings and pertinent negatives relevant to the chief complaint. [If not mentioned say normal] [Use the following systems as applicable:] - General: [Fever, chills, weight loss, night sweats, fatigue] - HEENT: [Headache, sore throat, runny nose, congestion, ear pain] - Respiratory: [Cough, SOB, wheeze, chest tightness] - Cardiac: [Chest pain, palpitations, edema] - GI: [Nausea, vomiting, diarrhea, constipation, abdominal pain] - GU: [Dysuria, frequency, urgency, hematuria, flank pain] - MSK: [Joint pain, muscle aches, swelling] - Derm: [Rash, itching, lesions] - Neuro: [Dizziness, syncope, focal weakness, numbness] - Psych: [Anxiety, depression, sleep concerns] [Only include systems with positive or pertinent negative findings. Omit normal/irrelevant systems.]

Mental Status Examination (MSE)

[Describe mental status examination findings. If normal, state: 'Mental status examination is normal.' Otherwise, specify abnormalities.]

Allergies

[List all drug and non-drug allergies, including reactions. If none, state 'No known drug allergies (NKDA).']

Current Medication

[List all current medications, including dose and frequency. If none, state 'No current medications.']

General

[Alert, oriented, in no acute distress / appears unwell (describe).]

HEENT

[Normocephalic, atraumatic. PERRLA, EOMI. Oropharynx clear, no erythema/exudates. TMs normal bilaterally.]

Neck

[Supple, no lymphadenopathy, no meningeal signs.]

Respiratory

[Normal respiratory effort. Clear to auscultation / wheezes / crackles (specify).]

Cardiovascular

[Regular rate and rhythm, no murmurs, rubs, gallops. Peripheral pulses intact.]

Abdomen

[Soft, non-tender, non-distended. No guarding or rebound. Bowel sounds normal.]

MSK

[Normal ROM, no joint swelling, tenderness, or deformity.]

Skin

[Warm, dry, no rash/lesions.]

Neurological

[Alert, oriented ×3. Speech normal. No focal deficits.]

Psychiatric

[Cooperative, normal mood and affect. State 'normal' unless otherwise mentioned.]

Assessment / Impression

[List primary issue first, followed by secondary issues if present. Number each diagnosis or problem. Use concise medical terminology.]

Plan

[Outline management and treatment plan for each problem listed above. Include investigations, referrals, and follow-up instructions as appropriate.]

Management / Treatment

[Specify medications prescribed, therapies initiated, and any procedures performed.]

Education & Counselling

[Document education provided regarding diagnosis, expected course, and management. State: 'Discussed diagnosis and expected course.' Medication instructions explained.]

Follow-Up

[Return to clinic if symptoms worsen or do not improve. ER precautions given. Follow up with primary care provider.]

Disposition

[Patient referred / sent to ER. Specify as appropriate.]