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General · Templates

Focused complaint note template

When the visit is one problem and you need speed without losing medical decision-making: a tight HPI, focused exam, concise assessment, and actionable plan—without chronic-care bloat.

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Template content

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

Focused Complaint Note

Chief Complaint
- Single primary problem in patient’s words; duration.

HPI (Focused)
- Onset, course, severity, location/radiation, quality, associated symptoms, aggravating/alleviating factors.
- Pertinent positives/negatives and red flags for this complaint.
- Treatments tried and response; relevant exposures or triggers.

Pertinent Background
- Only PMH, meds, allergies, and social factors that change today’s decision-making.

Exam
- Vital signs and focused exam for the complaint; key negatives.

Data
- Point-of-care tests, labs, or imaging obtained/reviewed today with interpretation.

Assessment
- Leading diagnosis/impression and brief differential as relevant.
- Acuity and risk.

Plan
- Diagnostics, therapeutics, work/activity guidance, and patient education.
- Follow-up timing and specific return precautions.

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

  • Prevents focused visits from expanding into full annual or multi-problem notes.
  • Keeps pertinent positives/negatives and red flags front and center.
  • Ideal for same-day slots, nurse visits with clinician cosign, and quick add-ons.
  • Clear disposition and return precautions every time.
  • 1Same-day single-problem visits
  • 2Urgent care–style focused complaints in clinic
  • 3Quick add-on problems during another visit

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
“Right ear pain for 2 days.”

HPI
Pain and pressure right ear after URI; mild hearing muffling; no fever, vertigo, facial weakness, or drainage. OTC ibuprofen partial relief. Swims occasionally; last swim 1 week ago.

Background
No DM or immunocompromise. NKDA. Not on anticoagulants.

Exam / Data
Temp 37.0, comfortable. Right TM erythematous, bulging, poor mobility; left TM normal. No mastoid tenderness. No effusion drainage.

Assessment
Acute right otitis media; low concern for mastoiditis or malignant OE.

Plan
Amoxicillin 875 mg BID ×5 days; ibuprofen PRN. Keep ear dry. Return 48–72h if worse, or sooner for high fever, severe headache, neck stiffness, or facial weakness. Message if not improved after antibiotics.

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.

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