Family Medicine · Templates

Acute sick visit template

Use this for same-day and acute slots where the story is a single complaint—cough, fever, UTI symptoms, back pain—and the note needs a tight HPI, focused exam, and clear disposition.

Template content

Copy or download, then paste into Wavo under My Templates.

Acute Sick Visit Note

Chief Complaint
- Patient’s stated reason for visit in their words when possible.

History of Present Illness
- Onset, duration, severity, progression, associated symptoms, and aggravating/alleviating factors.
- Pertinent positives/negatives and red-flag review (e.g., dyspnea, chest pain, dehydration, meningismus, focal neuro symptoms—as relevant to complaint).
- Exposures, sick contacts, recent travel, and prior similar episodes if discussed.
- Treatments tried and response.

Relevant History
- Pertinent PMH, medications, allergies, and immunization status (e.g., influenza, COVID-19) as available.
- Smoking/vaping or other relevant social history.

Review of Systems
- Focused ROS tied to the chief complaint.

Exam
- Vital signs and focused exam findings by system as performed.
- Document negative findings that influence medical decision-making.

Data / Point-of-Care Testing
- Rapid tests, UA, imaging, or labs ordered/reviewed today.

Assessment
- Clinical impression and differential with brief reasoning.
- Severity / risk stratification as clinically appropriate.

Plan
- Diagnostics, therapeutics (including OTC vs prescription), activity/work/school guidance.
- Patient education, contagion precautions when relevant, and explicit return precautions.
- Follow-up timing or PRN instructions.

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

  • Keeps acute visits from bloating into full chronic-care documentation.
  • Prompts pertinent negatives and red flags clinicians expect in URI/sick visits.
  • Return precautions and work/school guidance land in a predictable place.
  • Works for in-clinic and telehealth acute encounters with the same skeleton.
  • 1URI and respiratory sick visits
  • 2Same-day primary care acute slots
  • 3Episodic complaints (UTI, MSK strain, rash, etc.)

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
“Sore throat and congestion for 4 days.”

HPI
Symptoms began with rhinorrhea and scratchy throat; now mild productive cough and odynophagia. Subjective fever day 1 only. Denies dyspnea, chest pain, ear pain, rash, or neck stiffness. Two coworkers with similar illness. Tried acetaminophen and saline rinses with partial relief. Fully vaccinated for influenza this season.

Exam
Temp 37.2°C, HR 84, SpO2 99% RA. Mild nasal mucosal edema; oropharynx erythematous without exudate; no tonsillar asymmetry. Tympanic membranes clear. Lungs clear. No cervical adenopathy.

Assessment
Acute viral pharyngotonsillitis / URI. Low suspicion for strep given absence of fever, exudate, and adenopathy; rapid strep not indicated today.

Plan
Supportive care; honey/lozenges as needed; hydrate. Contagion precautions reviewed. Return if fever returns, breathing difficulty, inability to swallow, or symptoms worsen after day 7. May return to work if afebrile 24 hours and improving.

How Wavo automates this

What the product actually does with your template.

1. Add the template

Paste this content into My Templates, or start from a specialty-generated template and edit the sections.

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.

Put this template to work on your next visit

Start free, paste the template, and see how Wavo documents in your structure.