Urgent Care Telehealth Encounter Note

Date/Time: [Date and time of encounter]

Patient: [Full name and DOB / MRN]

Encounter Type: Urgent Care Telehealth

Modality: [Video / Audio-only] (If converted during visit, note when and why.)

Patient Location: [City, State] (If unknown, state why location could not be verified.)

Clinician Location: [City, State]

Participants: [Patient only / List others with roles] (If unknown, state why.)

Telehealth Consent: [Verbal / Written] (Document per policy; if not obtained, document reason.)

Callback Number Verified: [Yes / No] (If no, note alternate contact or reason unavailable.)

Subjective

[Chief complaint] (One sentence; may include a brief clarifying patient quote.)

[History of present illness as chronological narrative: onset, duration, severity, location, quality, progression, exposures, exacerbating/relieving factors, attempted treatments and responses, pertinent negatives asked. Integrate relevant medical history, medications, and allergies inline when informing assessment. Document history source if not patient. Note any telehealth constraints affecting history gathering.]

Objective

Vitals: [Patient-reported values with device source if known] (If unavailable, state why.)

Virtual Exam: [Pertinent findings by system, noting method for each—observed via video, patient-assisted, or unable to assess. Include only systems actually evaluated. For audio-only visits, explicitly state exam limitations.]

Data Reviewed: [Labs, imaging, prior records, patient-uploaded photos with dates and key results] (State "None" if none reviewed.)

Assessment & Plan

(Organize problems from highest to lowest acuity. Use symptom-based diagnoses when appropriate. Include differential only if uncertainty is clinically material.)

[Problem 1]: [Working diagnosis or symptom-based assessment]

[Clinical reasoning referencing pertinent findings; note what could not be assessed virtually and how this affects risk or need for in-person evaluation.]

• Treatment: [Medications with dose/route/frequency/duration; supportive measures]
• Testing/Referrals: [Ordered tests or referrals with location and timeframe] (Only include if applicable.)
• Safety-Netting: [Specific red-flag symptoms, expected improvement timeframe, and clear action instructions—e.g., "go to ED now," "call 911," "in-person evaluation within 24 hours"]

(If patient declines recommended escalation, document risks explained, patient understanding, and alternative plan agreed upon.)

[Problem 2]: [Working diagnosis or symptom-based assessment]

(Repeat structure above for additional problems as needed.)

Disposition: [Home management / In-person urgent care recommended / ED now / 911 / Telehealth follow-up] (Include time sensitivity.)

Follow-up: [Timeframe; how results will be communicated; contingency if patient cannot access follow-up]

Instructions Provided: [Confirm diagnosis explanation, medication counseling, and precautions given; note delivery method]

(If telehealth limitations materially affected diagnostic certainty, briefly note which assessments were limited and how this influenced threshold for escalation.)

Clinician Signature: [Name, credentials, date/time]