Urgent care runs on speed and volume. You may see 30 patients in a shift, each needing a complete note with clear discharge instructions — often while the next patient is already waiting. These templates are built for that pace.
Disclaimer: This template is for documentation structure only. Practices should adapt it to their clinical, legal, and organizational requirements.
Urgent care SOAP note template
SUBJECTIVE
Chief complaint: [Patient's stated reason for visit]
History of present illness:
- Onset:
- Duration:
- Severity (pain scale 0–10 if applicable):
- Location/radiation:
- Associated symptoms:
- Aggravating/relieving factors:
- Prior treatment attempted: [OTC medications, home remedies, prior visit for same]
- Relevant exposures: [Sick contacts, travel, occupational, animal bite, etc.]
Past medical history: [Active conditions relevant to the presenting complaint]
Medications: [Current medications — focus on those relevant to complaint and prescribing decisions]
Allergies: [Medication allergies with reaction type]
Review of systems: [Focused — pertinent positives and negatives related to chief complaint]
OBJECTIVE
Vital signs: BP ___ | HR ___ | Temp ___ | RR ___ | SpO2 ___ | Weight ___
General: [Appearance, distress level, overall impression]
Physical exam: [Focused exam — document systems relevant to chief complaint]
- [System 1]:
- [System 2]:
- [Additional systems as indicated]:
Point-of-care testing: [Strep, flu, COVID, UA, urine pregnancy, glucose, etc.]
Imaging: [X-ray results if obtained on site]
Procedures performed: [Laceration repair, I&D, splinting, etc. — see procedure section below]
ASSESSMENT
1. [Diagnosis] — [Brief supporting rationale]
Differential considered: [If diagnosis uncertain — list alternatives and why primary was chosen]
PLAN
1. Treatment:
- Medications prescribed: [Name, dose, route, frequency, duration, quantity, refills]
- Procedures: [If not detailed in separate procedure note — consent, technique, outcome]
- Wound care / splint care / other instructions: [Specific to presentation]
2. Discharge instructions:
- Diagnosis explained to patient in plain language: [Yes/No]
- Home care: [Ice, elevation, rest, wound care steps, etc.]
- Medications reviewed: [Dosing, timing, food/drug interactions, side effects discussed]
- Activity restrictions: [Specific — e.g., "no lifting >10 lbs for 5 days"]
- Return precautions: [Specific warning signs — see section below]
3. Follow-up:
- PCP follow-up recommended: [Within ___ days for ___]
- Specialist referral: [If applicable — type and urgency]
- Imaging/lab follow-up: [If results pending at discharge]
4. Work/school note: [Provided — dates, restrictions, without diagnosis unless authorized]
Patient verbalized understanding: [Yes/No]
Disposition: Discharged home / Transferred to ER / Admitted
Procedure add-on section
When you perform a procedure during an urgent care visit, add this section between the physical exam findings and the Assessment:
PROCEDURE
Procedure: [Name — e.g., laceration repair, incision and drainage, foreign body removal]
Indication: [Why the procedure was necessary]
Consent: [Informed consent obtained from patient — risks, benefits, alternatives discussed]
Anesthesia: [Type, agent, dose — e.g., "1% lidocaine with epinephrine, 5 mL local infiltration"]
Technique: [Brief description — e.g., "wound irrigated with NS, explored for foreign body — none found, closed with 4-0 nylon, 6 simple interrupted sutures"]
Findings: [What was found during the procedure]
Estimated blood loss: [If applicable]
Complications: [None / describe]
Specimen: [Sent to pathology / not applicable]
Post-procedure: [Dressing applied, tetanus administered, antibiotics prescribed]
Return precautions — common templates
Return precautions are a critical part of urgent care documentation. Below are examples for common presentations. Adapt the language to match what you actually tell the patient.
Fever / infection: Return or go to the ER if: fever above 103°F (39.4°C) that does not respond to antipyretics, inability to keep fluids down for more than 8 hours, worsening symptoms after 48 hours of treatment, new rash, stiff neck, or difficulty breathing.
Head injury: Return or go to the ER if: worsening headache, repeated vomiting, confusion or difficulty waking, seizure, weakness or numbness on one side, clear fluid from the nose or ear, unequal pupils.
Abdominal pain: Return or go to the ER if: pain becomes severe or constant, fever develops, blood in stool or vomit, inability to keep fluids down, abdominal rigidity or distension.
Laceration / wound: Return if: increasing redness, swelling, or warmth around the wound; pus or foul-smelling drainage; red streaks extending from the wound; fever; numbness or inability to move fingers/toes beyond the wound.
Musculoskeletal injury: Return if: increasing pain despite medication and ice, loss of sensation or circulation beyond the injury, inability to bear weight after 48 hours, significant swelling that does not improve.
Workflow tips for high-volume documentation
Prioritize the Plan section
In urgent care, the Plan — especially discharge instructions and return precautions — is often more important than a detailed HPI for patient safety. If you are short on time, make sure the Plan section is thorough. A sparse HPI with a solid Plan is better than the reverse.
Use structured chief complaints
If your EHR supports complaint-based templates, use them. A "sore throat" template that prepopulates relevant ROS questions and exam fields saves time and reduces missed items. Dictum's custom clinical templates can be configured for common urgent care presentations.
Document in real time when possible
Charting after a full shift of 30 patients leads to recall errors and longer documentation sessions. If you can review AI-drafted notes between patients — even for 60 seconds — you will catch details that would be lost by end of shift.
Template your return precautions
The return precautions above can be standardized for your most common presentations. Having pre-written precaution language that you adjust per patient is faster and more consistent than writing them from scratch each time.
Flag results pending at discharge
If a patient is discharged with labs or imaging results still pending, document this clearly in the Plan section and note who is responsible for follow-up. This protects both the patient and the clinician.
Related resources
For the foundational format, see the general SOAP note template. Learn how Dictum supports urgent care workflows with fast note generation built for high-volume settings. Set up AI-generated SOAP notes that include discharge instruction and return precaution sections by default.
Frequently asked questions
How is an urgent care SOAP note different from a primary care note? Urgent care notes are typically more focused — they address the presenting complaint without extensive chronic disease management. They emphasize clear discharge instructions, return precautions, and follow-up recommendations since the urgent care provider is usually not the patient's ongoing clinician.
What should discharge instructions include? Discharge instructions should cover the diagnosis in plain language, prescribed medications with dosing, home care measures, specific warning signs that require a return visit or ER evaluation, and follow-up timing with the patient's primary care provider or specialist.
How do I document a patient who leaves without being seen? Document the patient's arrival time, chief complaint if triaged, when they were last accounted for, and when they were found to have left. Note whether the patient was informed of risks and whether you attempted to contact them. Follow your facility's policy.
Do urgent care notes need to be sent to the patient's PCP? It is standard practice to provide a visit summary that can be shared with the patient's PCP, especially for findings that need follow-up. Include a recommendation in your note for the patient to follow up with their primary provider.
Can AI help with urgent care documentation speed? Yes. Dictum drafts SOAP notes from patient encounters or dictation, which is especially useful in high-volume urgent care settings where providers see 20-40 patients per shift. The AI draft gives you a starting point to review rather than documenting from scratch.
How do I document work or school notes? Document that a work/school excuse was provided, the dates covered, and any activity restrictions. Keep the content minimal — the note should confirm the visit occurred and state restrictions without disclosing the diagnosis unless the patient authorizes it.
See 30 patients without staying late to chart. Try Dictum free — AI-drafted urgent care notes that keep up with your pace.