Med-Peds Acute Visit Note (Same-Day/Urgent)

Encounter Details

Patient: [name, DOB, age, sex]

Date/Time: [date and time]

Visit Type: [same-day / urgent] | Mode: [in-person / video / phone]

Clinician: [clinician name and credentials]

Historian: [patient / parent / caregiver] (Note reliability if limited)

Interpreter: [language; modality] (Only include if interpreter was used)

Chief Complaint

[Chief complaint in patient/caregiver words] (One line; if multiple concerns, list primary complaint first)

Subjective

[History of present illness] (3–8 sentence narrative covering onset, duration, trajectory, severity with functional anchors such as sleep, oral intake, and activity level, associated symptoms, exposures/sick contacts, home management and response, and any prior evaluations for this episode. For pediatric patients, incorporate hydration/voiding status, caregiver-reported work of breathing, and behavior vs baseline. For adults, include pregnancy status/LMP and key comorbidities when they affect differential or management.)

Red-flag symptom screen:

• [Pertinent red-flag positives and negatives actually assessed] (Include only complaint-specific "can't miss" features that were evaluated; omit items not assessed)

Pertinent background: [Allergies with reaction types] | [Current medications relevant to acute illness] | [Targeted medical history that changes risk or management] | [Immunization context for pediatric patients when relevant to risk] (Include only elements that impact this encounter; if important information is unknown, state "unknown" with brief reason)

Objective

Vitals: [Temp with source, HR, RR, BP, SpO2 as relevant; weight required for pediatric visits or weight-based dosing]

Exam: [General appearance, distress level, and hydration status] | [Focused findings by pertinent systems only] (Use observable descriptors relevant to safety such as work of breathing, mental status, capillary refill, mucous membranes, ability to tolerate PO; include only systems needed for the complaint and disposition decision)

Testing: [Point-of-care tests with results] | [Send-out tests/cultures: pending with expected turnaround] | [Imaging with interpretation] (Include only if testing was performed; if testing was deferred, briefly document rationale when clinically salient)

Assessment & Plan

[Acute problem]: [Working diagnosis with severity and brief risk statement] (State focused differential of 2–5 items emphasizing can't-miss diagnoses; document why dangerous alternatives are less likely based on specific findings)

• Treatment: [Medications with dose, route, frequency, duration; use weight-based dosing and mL-only for pediatric liquids] | [Non-pharmacologic care] (If prescribing antibiotics, include diagnostic justification; if not prescribing, document supportive-care rationale)
• Patient/Caregiver education: [Expected course and timeframe for improvement] | [Key instructions] | [Medication counseling points for new prescriptions]
• Disposition: [home / ED referral / observation] with rationale for why current level of care is appropriate
• Follow-up: [Specific timeframe and conditions for follow-up]
• Return precautions: [Symptom-based, actionable criteria tailored to the complaint]
• Pending results plan: [Who will contact patient/family, expected timeframe, and action for positive vs negative results] (Only include if tests are pending)
• Shared decision-making: [Options discussed, patient/caregiver preference, confirmation of understanding] (Only include if preference-sensitive decisions or declined recommendations occurred)

(Omit sections or elements not relevant to this encounter; if information was sought but unavailable, document as unknown with reason)