Urgent Care: Step-by-Step Guide on How to Write SOAP Notes

Updated January 2026

Urgent care documentation requires balancing efficiency with thoroughness in a high-volume, episodic care environment. Unlike primary care, urgent care visits focus on acute presentations with the goal of stabilizing patients, ruling out emergent conditions, and facilitating appropriate follow-up with their primary care provider (PCP). This guide covers documentation best practices for the most common urgent care presentations.

Unique Aspects of Urgent Care Documentation

Urgent care documentation differs from other clinical settings in several key ways:

1. High Volume: Providers may see 20-40+ patients per shift, requiring efficient documentation workflows
2. Episodic Care: No established patient relationship; each visit is often a first encounter
3. Focused Encounters: Documentation centers on the chief complaint rather than comprehensive care
4. PCP Handoff: Notes must facilitate continuity with the patient's primary care provider
5. Acuity Assessment: Critical to document that emergent conditions were considered and ruled out
6. Return Precautions: Clear documentation of warning signs and when to seek emergency care
7. Work/School Notes: Frequent requests for documentation supporting time off

Subjective Section (S)

The Subjective section in urgent care must efficiently capture the essential information needed for clinical decision-making while documenting pertinent history for the focused complaint.

Subjective Section (S) Components

1. Chief Complaint:

   • Brief statement with duration
   • Mode of presentation (walk-in, telehealth, employer referral)
   • Example: "Sore throat and fever x 3 days, walk-in"

2. History of Present Illness:

   • Focused on the acute presentation
   • OLDCARTS format (Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, Severity)
   • Associated symptoms relevant to differential
   • Home treatments attempted
   • Example: "28-year-old female with 3-day history of sore throat, subjective fever, and body aches. Denies cough, rhinorrhea, or rash. Tried ibuprofen with minimal relief. No sick contacts known. No recent travel."

3. Pertinent Review of Systems:

   • Focused on ruling out emergent conditions
   • Document red flag symptoms asked and denied
   • Example: "Denies difficulty breathing, drooling, neck stiffness, or severe headache."

4. Past Medical History:

   • Focus on conditions relevant to chief complaint
   • Immunocompromising conditions, chronic diseases
   • Example: "Type 2 diabetes, well-controlled. No history of recurrent strep infections."

5. Medications and Allergies:

   • Current medications with attention to anticoagulants, immunosuppressants
   • Drug allergies with reaction type
   • Example: "Metformin 1000mg BID. NKDA."

6. Social History:

   • Pertinent to presentation only
   • Occupation if relevant (work injury, exposure)
   • Example: "Works in daycare, non-smoker."

7. Primary Care Provider:

   • Document PCP name and practice if known
   • Note if patient has no PCP (important for follow-up planning)
   • Example: "PCP: Dr. Smith at Main Street Family Medicine" or "No established PCP"

Focused HPI Templates by Common Complaint

Upper Respiratory Infection (URI)

Urinary Tract Infection (UTI)

Laceration/Wound

Sprain/Strain/Musculoskeletal Injury

Skin Rash

Example Subjective Section for Urgent Care (URI)

Objective Section (O)

The Objective section documents focused physical examination findings and point-of-care testing results essential for clinical decision-making in the urgent care setting.

Objective Section (O) Components

1. Vital Signs:

   • Temperature (method), heart rate, respiratory rate, blood pressure, SpO2
   • Weight (important for pediatric medication dosing)
   • Example: "Temp 100.8°F (oral), HR 88, RR 16, BP 122/78, SpO2 98% RA"

2. General Appearance:

   • Degree of illness (well-appearing, mildly ill, moderately ill, toxic)
   • Hydration status
   • Distress level
   • Example: "Alert, mildly ill-appearing male in no acute distress"

3. Focused Physical Examination:

   • Targeted to chief complaint
   • Document positive and pertinent negative findings
   • System-specific examinations based on presentation

4. Point-of-Care Testing:

   • Rapid strep, rapid flu/COVID, urinalysis
   • Fingerstick glucose
   • Document results with timing
   • Example: "Rapid strep: Negative. Rapid COVID/Flu: Negative for both."

5. Wound Documentation (for lacerations):

   • Location, length, depth, shape
   • Wound bed (clean, contaminated, foreign body)
   • Neurovascular status distal to injury
   • Example: "2.5 cm linear laceration to left palm, 3mm depth, clean wound bed, no foreign body visible, intact sensation and capillary refill distal to wound"

6. Imaging Results:

   • X-ray findings for MSK injuries
   • Document normal findings when ruling out fracture
   • Example: "XR left ankle 3 views: No fracture or dislocation. Soft tissue swelling noted laterally."

Physical Exam Templates by Common Complaint

URI/Pharyngitis Exam

UTI Physical Exam

Laceration/Wound Exam

MSK/Sprain Exam

Example Objective Section for Urgent Care (URI)

Assessment Section (A)

The Assessment must clearly document the working diagnosis, acuity level, and importantly, the red flags that were considered and ruled out. This is critical for both clinical reasoning and medicolegal documentation in urgent care.

Assessment Section (A) Components

1. Primary Diagnosis:

   • Most likely diagnosis with ICD-10 code
   • Specify acuity and severity when applicable
   • Example: "Acute viral upper respiratory infection (J06.9)"

2. Acuity Assessment:

   • Document why this is appropriate for urgent care vs. ED
   • Confirm stability for outpatient management
   • Example: "Low acuity, stable for outpatient management"

3. Red Flags Ruled Out:

   • Document serious conditions considered and excluded
   • Critical for liability protection
   • Example: "No evidence of peritonsillar abscess, epiglottitis, or bacterial pharyngitis"

4. Differential Diagnoses:

   • Other conditions considered
   • Why they were excluded or less likely

5. Referral Criteria Assessment:

   • Document if patient meets or does not meet criteria for ED referral
   • If specialty referral indicated, document reason
   • Example: "Does not meet criteria for ED transfer. No signs of severe dehydration, respiratory distress, or systemic toxicity."

Assessment Framework for Common Urgent Care Diagnoses

Example Assessment Section for Urgent Care (URI)

Plan Section (P)

The Plan in urgent care must include treatment, clear return precautions, work/school documentation if requested, and explicit PCP follow-up instructions.

Plan Section (P) Components

1. Treatment:

   • Medications with specific dosing
   • Symptomatic treatment recommendations
   • Duration of therapy

2. Work/School Notes:

   • Document if requested and provided
   • Specific dates and restrictions
   • Example: "Work note provided for [dates]. May return to work [date] without restrictions."

3. PCP Follow-Up:

   • Specific timeframe
   • Conditions requiring earlier follow-up
   • Assistance with PCP referral if patient unassigned

4. Return Precautions:

   • Specific warning signs requiring return to urgent care or ED
   • Clear, patient-friendly language
   • Example: "Return immediately if you develop difficulty breathing, inability to swallow, high fever >103°F, or worsening symptoms"

5. Patient Education:

   • Expected course of illness
   • Home care instructions
   • Medication instructions

Plan Templates by Common Complaint

URI/Viral Pharyngitis Plan

UTI Treatment Plan

Laceration Treatment Plan

Sprain Treatment Plan

Example Plan Section for Urgent Care (URI)

AI-Assisted Documentation for Urgent Care

AI-powered documentation tools are particularly valuable in high-volume urgent care settings where documentation efficiency directly impacts patient flow and provider satisfaction. According to AMA research, 66% of healthcare providers now use AI tools, with urgent care being an ideal setting for AI-assisted documentation.

High-Volume Efficiency with AI Documentation

Benefits for Urgent Care:

• Reduced documentation time per encounter (30-50% time savings)
• Consistent capture of return precautions and red flags
• Standardized templates for common presentations
• Real-time note generation during patient encounters
• Reduced after-shift documentation burden

What AI Captures Well in Urgent Care:

• Patient history and chief complaint
• Review of systems discussions
• Return precautions communicated
• Discharge instructions given
• Medication reconciliation discussions
• Work/school note requests

What Requires Careful Review:

• Precise vital signs and POC test results (verify values)
• Wound measurements and descriptions (confirm accuracy)
• Medication dosing (critical to verify)
• Red flags ruled out (ensure complete documentation)
• Timing of symptom onset (verify patient's reported timeline)
• Follow-up instructions (confirm PCP information)

Tips for AI Documentation in Urgent Care

1. State diagnoses clearly: "The diagnosis is acute viral upper respiratory infection"
2. Verbalize red flags: "I assessed for and ruled out peritonsillar abscess - there is no trismus, uvula is midline"
3. Dictate return precautions: "Patient should return if they develop difficulty breathing, high fever, or worsening symptoms"
4. Confirm PCP: "Patient's primary care provider is Dr. Smith at Main Street Medical"
5. Document acuity: "This is a low-acuity presentation appropriate for urgent care management"

AI Documentation Workflow for High-Volume Settings

For more details, see our complete AI-Assisted Documentation Guide.

Telehealth Urgent Care Documentation (Virtual Urgent Care)

Virtual urgent care has become a significant portion of urgent care visits, particularly for lower-acuity presentations. Per CMS 2026 guidelines, telehealth services continue to be covered with specific documentation requirements.

Appropriate Virtual Urgent Care Presentations

Well-Suited for Telehealth:

• Upper respiratory infections
• Urinary symptoms (uncomplicated)
• Conjunctivitis (pink eye)
• Skin rashes (with good photo/video quality)
• Medication refills (acute, short-term)
• Gastrointestinal complaints (mild)
• Musculoskeletal pain (mild, no trauma concern)
• Mental health concerns (acute anxiety, stress)
• Follow-up visits

Requires In-Person Evaluation:

• Lacerations or wounds requiring repair
• Suspected fractures
• Abdominal pain requiring examination
• Chest pain (should go to ED)
• Shortness of breath (should go to ED)
• High fever with significant symptoms
• Conditions requiring POC testing for diagnosis

Telehealth Documentation Requirements

Virtual Urgent Care Red Flags

Document clear guidance for when patient should seek in-person care:

For complete telehealth documentation guidance, see our Telehealth SOAP Notes Guide.

Free Urgent Care SOAP Note Template

Related Resources

• Emergency Medicine SOAP Notes - For higher acuity presentations
• Telehealth SOAP Notes Guide
• AI-Assisted Documentation Guide
• Nurse Practitioner SOAP Notes
• Physician Assistant SOAP Notes