Acute illness visit
United States | Urgent care

Blank documentation outlines for US practice. Adapt to the encounter and your practice requirements; complete only findings and care actually documented.

ENCOUNTER
Patient name: [ ]
Date of birth: [ ]
Date and time of encounter: [ ]
Clinician: [ ]

HISTORY
Chief concern, onset and symptom course: [ ]
Associated symptoms and pertinent negatives actually elicited: [ ]
Exposures and treatment already tried: [ ]
Relevant history, medications and allergies: [ ]

EVALUATION
Vitals measured, with units and time: [ ]
Focused examination findings: [ ]
Testing obtained, results and pending tests: [ ]

ASSESSMENT AND MANAGEMENT
Working diagnosis and differential: [ ]
Reasoning for testing and treatment decisions: [ ]
Treatment provided and response: [ ]
Disposition and rationale: [ ]
Pending-result follow-up owner and communication plan: [ ]

FOLLOW-UP
Follow-up timing and purpose: [ ]
Return precautions discussed: [ ]
Patient questions and understanding: [ ]