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Urgent care visit template
Tuned for urgent care pace: a single acute complaint, focused exam, common procedures (laceration, I&D, splinting), clear MDM, and discharge or referral—without a full ED boarding narrative.
Template content
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Urgent Care Visit Note Chief Complaint - Patient’s stated reason for visit. HPI - Onset, mechanism (if injury), severity, associated symptoms, pertinent negatives, and treatments tried. - Occupational or school context if relevant (work injury, return-to-work needs). History - Pertinent PMH, medications, allergies, immunization status (e.g., tetanus), and last menstrual period / pregnancy status when indicated. - Preferred pharmacy and work/school constraints as discussed. Exam - Vital signs and focused exam; injury exams include neurovascular status and joint/ROM when relevant. Procedures / Testing - Point-of-care tests, imaging ordered/interpreted, and procedures performed (with consent, technique, findings, complications, and aftercare). - Specimens sent if any. Assessment / MDM - Clinical impression, differential, and reasoning. - Decision for discharge home vs referral to ED/specialty, with criteria used. Plan - Medications, durable medical equipment, wound/injury care, activity restrictions, work/school notes. - Return precautions and follow-up (PCP, specialty, wound check). - Patient education documented.
When to use this template
What makes the structure useful, and which visits it fits best.
Why this template works
Structural advantages for real documentation
Best for
Visit types and clinicians who use this format
- Matches urgent care workflows better than a hospital H&P or wellness note.
- Makes room for procedures and point-of-care testing common in UC.
- Keeps referral-to-ED criteria explicit when escalation is needed.
- Works across occupational, pediatric-capable, and general UC clinics with light edits.
- 1Urgent care episodic visits
- 2Minor procedures and injury visits
- 3Occupational and after-hours acute care
Example output shape
Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.
Chief Complaint Laceration to left forearm after kitchen knife slip 45 minutes ago. HPI 3 cm linear laceration on volar forearm; bleeding controlled with pressure. Last tetanus booster ~8 years ago. No numbness/weakness distal to injury. No anticoagulants. Right-hand dominant. Exam BP 124/78, HR 80. 3 cm superficial laceration through dermis, no visible tendon/foreign body. Sensation intact median/ulnar/radial distributions; capillary refill <2 sec; full finger flexion/extension without pain over tendons. Procedure Informed consent obtained. Wound irrigated with sterile saline; closed with 4 simple interrupted 4-0 nylon sutures under local lidocaine. Good approximation; hemostasis achieved. Dressing applied. No complications. Assessment Simple laceration, left forearm. Low concern for tendon injury. Plan Tetanus-diphtheria booster given. Keep wound clean/dry 24 hours, then gentle washing; antibiotic ointment and daily dressing changes. Suture removal 10–12 days. Return for increasing redness, purulent drainage, fever, or numbness/weakness. Activity: avoid heavy lifting with left arm × 7 days. Work note provided.
How Wavo automates this
What the product actually does with your template.
2. Record or dictate
Capture the encounter with ambient recording or dictation. Wavo structures the note using your template.
3. Review and sign
Edit with Smart Transform if needed, then export or copy into your EHR. You stay responsible for the final note.
Related templates
Put this template to work on your next visit
Start free, paste the template, and see how Wavo documents in your structure.