Acute Sick Visit Note (Outpatient)

Date/Time: [Date and time of encounter]

Patient: [Patient name and identifier]

Provider: [Provider name and credentials]

Location: [Clinic/site or telehealth setting]

Source of History: [Source(s) providing history and interpreter use if applicable]

Allergies: [Allergy list / no known drug allergies / unable to verify: reason]

Medications: [Medication list with verification status] (If unable to verify, state reason.)

Chief Complaint

[Chief complaint in patient's own words with duration]

History of Present Illness

[Focused narrative HPI] (Include onset, duration, progression, severity; relevant context/exposures such as sick contacts, travel, or mechanism if injury; pertinent associated symptoms and red-flag negatives informing risk; treatments attempted and response; relevant comorbidities affecting today's differential or management including immunosuppression, anticoagulant use, or pregnancy potential when relevant. End with patient-stated priorities if expressed.)

Objective

Vitals: [Vital signs with available parameters]

Exam:

• [General appearance]
• [Targeted system findings with pertinent positives and negatives] (Include only systems examined; add bullets per system as needed.)

Data: [Point-of-care tests, labs, imaging, or records reviewed with brief interpretation] (Include only if applicable. Note telehealth exam limitations if relevant.)

Assessment & Plan

[Diagnosis/working diagnosis with certainty level]

[Key supporting findings and brief differential reasoning explaining why serious alternatives are less likely]

• Diagnostics: [Studies ordered/reviewed and clinical question addressed]
• Tests offered but declined: [Recommendation, risk discussion, and patient's informed decision] (Only include if applicable.)
• Treatment: [Medications with dose/route/frequency/duration; non-pharmacologic measures] (Include supportive care and activity restrictions as applicable.)
• Return precautions: [Specific red-flag symptoms and timeframe prompting re-evaluation or ED visit]
• Follow-up: [Who will follow up, how results communicated, and timeframe] (If pending results could change management, document contingency plan.)

[Additional problem addressed today]

(Only include if another acute issue was evaluated. Use same structure as above.)

Disposition

[Discharged with outpatient management / scheduled for recheck / referred to ED or higher level of care] (Include mode of transport if referred.)