Same-Day Acute Visit Note (Adult Internal Medicine)

Date/Time: [Date and time of encounter]

Clinician: [Clinician name and credentials]

Location: [Clinic/site or telehealth originating site]

Visit Type: [in-person / telehealth] (If telehealth, note modality and any limitations on history or examination.)

Chief Complaint

[Primary symptom(s) and duration in one sentence, ordered by patient priority]

History

[Focused narrative of acute presentation] (Write 3–8 sentences integrating: symptom characterization—onset, duration, progression, severity, quality, triggers, associated symptoms; clinically relevant red flags present or absent for the differential; pertinent context such as exposures, self-treatments tried, or prior evaluations for this episode. Integrate pertinent medical history, current medications—especially recent antibiotics, immunosuppressants, anticoagulants—and allergies with reaction types only when they impact risk, differential, or treatment. Include pregnancy possibility when relevant to workup or therapy. If a targeted review of systems beyond the HPI was performed, briefly include by system; otherwise omit. Omit elements not obtained; explicitly note gaps only when clinically significant.)

Objective

Vitals: [Relevant vitals as obtained] (If not obtained, state why when clinically significant.)

Exam: [Focused physical exam findings by system examined; pertinent positives and negatives only] (Note limitations if telehealth.)

Data: [Point-of-care test results; pertinent prior labs/imaging reviewed; tests ordered today] (Clearly distinguish pending tests from available results.)

Assessment & Plan

(List problems with the most clinically urgent first. Include chronic conditions only if actively addressed this visit.)

[Problem 1]: [Working diagnosis or clinical syndrome]

[Severity/stability statement and brief synthesis of reasoning] (Include differential diagnoses when uncertainty exists—especially dangerous alternatives—with rationale for why less likely. Reference key red flags present or absent that informed disposition.)

• Diagnostics: [Tests ordered with rationale; who follows up on pending results and how patient will be notified]
• Treatment: [Medications with name, dose, route, frequency, duration; non-pharmacologic measures; antibiotic rationale when applicable]
• Disposition: [Outpatient management / ED referral / admission] (Include reasoning if not routine outpatient.)
• Follow-up: [Timeframe and modality]
• Return precautions: [Specific symptoms or changes warranting urgent or emergent care, tailored to the differential]
• Counseling/shared decision-making: [Key counseling points; risks/benefits/alternatives discussed; patient preferences] (Include only for preference-sensitive decisions.)

[Problem 2]: [Working diagnosis or clinical syndrome]

(Include only if an additional problem was actively addressed. Follow the same structure as Problem 1.)