Urgent Care — General Visit Template
The Urgent Care General Visit Template is designed for urgent care providers evaluating patients with common acute complaints. This efficient template documents focused history, physical examination, point-of-care testing, and treatment for conditions like URI, UTI, lacerations, sprains, and minor injuries. Supports appropriate billing for E/M services (99201-99215) and includes streamlined sections for chief complaint, HPI, focused exam, assessment, and disposition. Ideal for urgent care centers, retail clinics, and walk-in facilities handling acute but non-emergent presentations.
Template
Visit Information
Date: [Date]
Time in: [Time]
Chief complaint: [Primary concern]
Acuity: Routine / Urgent / Semi-urgent
Patient Information
Age: [X] years
Sex: Male / Female
Last PCP visit: [Date] / No PCP
Pharmacy: [Name, location]
Vital Signs
BP: [X/X]
HR: [X]
RR: [X]
Temp: [X]°F / [X]°C
SpO2: [X]%
Weight: [X] lbs / kg
Pain: [X]/10
Chief Complaint
[Primary symptom]
Duration: [X] days/hours
Onset: Sudden / Gradual
History of Present Illness
[Focused narrative of presenting complaint]
For Respiratory Complaints
Symptoms: [ ] Cough [ ] Congestion [ ] Sore throat [ ] Runny nose [ ] Fever
[ ] Ear pain [ ] Sinus pressure [ ] Headache [ ] Body aches
Cough: Dry / Productive — Sputum color: [X]
Fever: Max temp: [X]°F, Duration: [X] days
Sick contacts: Yes / No
COVID/Flu exposure: Yes / No / Unknown
For Urinary Complaints
Symptoms: [ ] Dysuria [ ] Frequency [ ] Urgency [ ] Hematuria [ ] Flank pain
[ ] Fever [ ] Suprapubic pain [ ] Vaginal discharge (if female)
Last menstrual period: [Date] (if applicable)
Prior UTIs: None / [Frequency]
Sexual activity: [If relevant]
For Musculoskeletal Complaints
Mechanism: [How injury occurred]
Location: [Body part, side]
Swelling: Yes / No
Weight-bearing: Able / Unable
Prior injuries: Same area: Yes / No
For Skin/Wound Complaints
Type: Laceration / Abrasion / Bite / Burn / Rash / Abscess
Location: [Anatomic site]
Size: [X] cm
Contamination: Clean / Dirty / [Source]
Time since injury: [X] hours
Tetanus status: Up to date / Needs update / Unknown
For Other Complaints
[Relevant focused history]
Review of Systems
Constitutional: [ ] Fever [ ] Chills [ ] Fatigue
[System-specific based on complaint - focused review]
All other systems negative or as noted.
Past Medical History
Relevant conditions: [List key conditions]
Relevant surgeries: [List if pertinent]
Medications
[Current medications]
Allergies
[Drug allergies and reactions]
Social History
Tobacco: Yes / No
Alcohol: [Use]
Occupation: [If relevant]
Physical Examination
General
Appearance: Well-appearing / Ill-appearing / Uncomfortable
Distress: None / Mild / Moderate
System-Specific Examination
Respiratory/ENT:HEENT:
- TMs: Clear bilaterally / Erythematous [Side] / Bulging / Effusion
- Nasal: Clear / Congested / Purulent drainage
- Throat: Clear / Erythematous / Exudate / Tonsillar enlargement [Grade]
- Sinus tenderness: None / Maxillary / Frontal
Neck: Supple / Lymphadenopathy [Location]
Lungs: CTAB / Wheezes / Rhonchi / Rales [Location]
Abdomen: Soft, non-tender / Tender [Location]
CVA tenderness: None / [Side]
Pelvic (if indicated): [Findings]
Inspection: Normal / Swelling / Deformity / Ecchymosis
Palpation: Tenderness [Location]
ROM: Full / Limited [Degrees]
Stability: Stable / Unstable
Neurovascular: Intact / [Deficit]
Weight-bearing: Able / Unable
Wound description: [Type, length x width x depth]
Edges: Clean / Irregular / Devitalized
Base: [Healthy, necrotic, foreign body]
Surrounding skin: Normal / Erythema / Induration / Cellulitis
Neurovascular distal: Intact / [Deficit]
Tendon function: Intact / Impaired
Point-of-Care Testing
[ ] Rapid strep: Negative / Positive
[ ] Rapid flu: Negative / Positive (A / B)
[ ] COVID rapid: Negative / Positive
[ ] Urinalysis:
- LE: Neg / Trace / [+]
- Nitrites: Neg / Pos
- Blood: Neg / [+]
- WBC: [X]
- Bacteria: None / [+]
[ ] Urine pregnancy: Negative / Positive
[ ] Fingerstick glucose: [X] mg/dL
[ ] Monospot: Negative / Positive
[ ] Other: [Test, result]
Imaging (if obtained)
X-ray [Body part]: [Interpretation]
- Fracture: None / [Description]
- Soft tissue: Normal / [Findings]
Assessment
1) [Primary diagnosis]
2) [Secondary diagnosis if applicable]
Plan
Prescriptions
1) [Medication] [Dose] [Route] [Frequency] [Duration] — Qty: [X], Refills: [X]
2) [Additional medications as needed]
Over-the-Counter Recommendations
- [OTC medications with specific instructions]
Procedures Performed (if applicable)
- [ ] Wound irrigation and repair — Sutures: [Type, number] / Staples / Dermabond
- [ ] Tetanus: Tdap / Td — given
- [ ] Incision and drainage
- [ ] Splinting — Type: [X]
- [ ] Nebulizer treatment
- [ ] IM/IV medications: [Medication, dose]
Activity/Restrictions
- Work/school note: [Days off] / No restrictions / Modified duty
- Activity: [Specific restrictions - weight-bearing, lifting, etc.]
- Return to normal activity: [Timeframe]
Follow-up
- PCP: [Timeframe] / Establish care recommended
- Specialist: [If needed, type, timeframe]
- Return to urgent care if: [Specific warning signs]
- [ ] Fever >101°F
- [ ] Worsening symptoms
- [ ] New symptoms: [Specific]
- [ ] Not improving in [X] days
Referral to ED
Not indicated / Recommended for: [Reason]
Patient Education
- Diagnosis explained in understandable terms
- Expected course of illness: [Duration, what to expect]
- Warning signs reviewed: [Specific to condition]
- Medication instructions: [Key points]
- Written discharge instructions provided
Disposition
Disposition: Discharged / Referred to ED / [Other]
Time out: [Time]
Condition at discharge: Stable / Improved
Provider
[Provider name, credentials]
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