Minor Urgent Care Form (UTI)
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Date of Visit
*
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Chief Complaint:
Patient presents with urinary complaints, including dysuria, frequency, and/or urgency. Patient suspects a possible urinary tract infection.
History of Present Illness (HPI):
Patient reports urinary frequency, urgency, and burning with urination. Denies flank pain, fever, nausea, vomiting, or hematuria. No history of recurrent or complicated urinary tract infections reported. No recent antibiotic use. Denies concerns for pregnancy or sexually transmitted infections at this time.
How many days have you experienced the above symptoms?
*
Review of Symptoms (ROS):
Constitutional: Denies fever, chills fatigue. Genitourinary: Reports dysuria, frequency, urgency. Denies hematuria, flank pain, urinary retention or pelvic pain. Gastrointestinal: Denies nausea, vomiting, abdominal pain, diarrhea. Cardiovascular: Denies chest pain, palpitations. Respiratory: Denies cough, shortness of breath. Neurological: Denies dizziness, headache or confusion. Skin: Denies rash or new skin changes.
Physical Exam:
General: Alert, oriented, in no acute distress. Abdomen: Soft, non-tender, non-distended. No CVA tenderness bilaterally. GU: Exam deferred/not indicated unless symptoms progress. Heart: Regular rate and rhythm; no murmurs. Lungs: Clear to auscultation bilaterally. Skin: Warm, dry, intact. Neuro: Cranial nerves grossly intact.
Assessment:
1. Dysuria--likely uncomplicated urinary tract infection. 2. Rule out uncomplicated UTI or pyelonephritis. 3. Monitor for progression
Plan:
Urine dip/UA obtained if available. Encourage hydration and supportive care. Discussed warning signs and red flag symptoms that require emergent care. Patient verbalized understanding and agrees with plan.
Prescribed medications:
Injections given in office:
Red Flag Symptoms (Patient Denies):
Fever > 101.5°F. Flank pain or CVA tenderness. Hematuria (gross blood in urine). Inability to urinate/urinary retention. Severe abdominal or pelvic pain. Nausea/vomiting with inability to tolerate fluids. Confusion or altered mental status. Rapidly worsening or recurrent symptoms.
Stacy Sims, FNP-C
*
Continue
Should be Empty: