Injury assessment
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: [ ]

INJURY HISTORY
Date, time and mechanism: [ ]
Site and laterality: [ ]
Symptoms, function and relevant prior injury: [ ]
Relevant medical history, medications and allergies: [ ]

EVALUATION
Vitals measured, with units: [ ]
Examination findings including relevant functional and neurovascular assessment: [ ]
Imaging or other tests and interpretation: [ ]

ASSESSMENT AND MANAGEMENT
Working diagnosis and differential: [ ]
Treatment, immobilization or other intervention actually provided: [ ]
Reassessment and response: [ ]
Activity guidance discussed: [ ]
Referral or transfer decision and rationale: [ ]

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