Urgent Care SOAP Note
Created by
Paul Hughes
Specialty
General Practitioner
Last edited
10/20/2026
Uses
0 times
Tags
General Practitioner
About this template
A structured template for documenting urgent care appointments in SOAP format. It covers the patient’s reported history, objective findings, assessment, and explicitly stated management plan.
Preview template
Subjective
- Acute dysuria, urinary frequency, and suprapubic discomfort for 3 days.
- No visible haematuria, fever, rigors, flank pain, or vaginal discharge.
- PMH: Mild asthma, appendicectomy (2015).
- Salbutamol 100 mcg inhaled PRN, desogestrel 75 mcg PO OD.
- Non-smoker, drinks 4 units of alcohol per week, works as an office administrator.
- NKDA.
Objective
- BP 118/74 mmHg, HR 76 bpm, Temp 36.8 °C, RR 14 breaths/min, SpO2 99 % on room air.
- Alert, comfortable at rest. Abdomen soft, mild suprapubic tenderness, no CVA tenderness, no guarding or rebound.
- Urine dipstick: Leukocytes 3+, Nitrites positive, Blood 1+, Protein trace, Glucose negative. Urine pregnancy test negative.
Assessment
- Acute uncomplicated lower urinary tract infection.
- Systemically well with no clinical features of pyelonephritis.
Plan
- Nitrofurantoin (Macrobid®) 100 mg MR PO BID for 3 days.
- Paracetamol 1,000 mg PO QID PRN for pain.
- Follow up with GP if symptoms do not resolve after completing the antibiotic course.
- Advised to maintain adequate oral fluid intake and counselled on red flag symptoms (fever, rigors, loin pain, vomiting, frank haematuria) requiring urgent medical review.
- No referrals required at this stage.
How to use this template
This template can be used to assist with various tasks in the medical field. You can use it to generate notes, manage patient information, or assist with diagnosis and the Assessment and Plan. To use this template, simply click the “Use Template” button above. If you have any questions or need assistance, feel free to reach out to the support team or refer to the description and example output provided above.