# Urgent Care Triage Assessment

| Form ID | FRM-UC-001 | Revision | 1.0 |
|---------|-------------|----------|-----|

---

## Patient Information

| Field | Entry |
|-------|-------|
| Patient Name | |
| MRN | |
| Date of Birth | |
| Age | |
| Sex | ☐ Male ☐ Female |
| Date | |
| Time of Arrival | |
| Time of Triage | |

---

## Chief Complaint

*In patient's own words:*

**Duration of Symptoms:**

---

## Vital Signs

| Parameter | Value | Normal? |
|-----------|-------|---------|
| Temperature | °F / °C | ☐ Yes ☐ No |
| Heart Rate | bpm | ☐ Yes ☐ No |
| Respiratory Rate | /min | ☐ Yes ☐ No |
| Blood Pressure | / mmHg | ☐ Yes ☐ No |
| SpO2 | % on ☐ RA ☐ O2 ___L | ☐ Yes ☐ No |
| Pain Score | /10 | |
| Weight | kg / lbs | |
| Blood Glucose (if indicated) | mg/dL | ☐ N/A |

---

## Allergies

☐ No Known Drug Allergies (NKDA)
☐ No Known Allergies (NKA)

| Allergen | Type | Reaction |
|----------|------|----------|
| | ☐ Drug ☐ Food ☐ Environmental | |
| | ☐ Drug ☐ Food ☐ Environmental | |
| | ☐ Drug ☐ Food ☐ Environmental | |

---

## Current Medications

| Medication | Dose | Frequency |
|------------|------|-----------|
| | | |
| | | |
| | | |
| | | |

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## Brief Medical History

☐ None significant

| Condition | Yes | Condition | Yes |
|-----------|-----|-----------|-----|
| Diabetes | ☐ | Heart Disease | ☐ |
| Hypertension | ☐ | Lung Disease/Asthma | ☐ |
| Kidney Disease | ☐ | Liver Disease | ☐ |
| Blood Clots/DVT | ☐ | Cancer | ☐ |
| Seizures | ☐ | Immunocompromised | ☐ |
| Pregnancy | ☐ (LMP: _______) | Other: | ☐ |

---

## History of Present Illness

### OPQRST

| Element | Response |
|---------|----------|
| **O**nset: When did this start? | |
| **P**rovocation: What makes it better/worse? | |
| **Q**uality: Describe the symptom | |
| **R**adiation: Does it travel anywhere? | |
| **S**everity: How bad is it (0-10)? | |
| **T**iming: Constant or comes and goes? | |

### Associated Symptoms

| Symptom | Present | Symptom | Present |
|---------|---------|---------|---------|
| Fever/Chills | ☐ | Nausea/Vomiting | ☐ |
| Headache | ☐ | Diarrhea | ☐ |
| Shortness of Breath | ☐ | Urinary Symptoms | ☐ |
| Chest Pain | ☐ | Rash | ☐ |
| Dizziness | ☐ | Weakness | ☐ |
| Cough | ☐ | Vision Changes | ☐ |
| Sore Throat | ☐ | Numbness/Tingling | ☐ |

---

## Quick Look Assessment

### General Appearance

| Observation | Finding |
|-------------|---------|
| Alert and oriented | ☐ Yes ☐ No |
| In acute distress | ☐ Yes ☐ No |
| Skin color | ☐ Normal ☐ Pale ☐ Flushed ☐ Cyanotic |
| Respiratory effort | ☐ Normal ☐ Labored |
| Ambulation | ☐ Independent ☐ Assisted ☐ Wheelchair ☐ Stretcher |
| Obvious injuries | ☐ None ☐ Present: _______ |

---

## Screening Questions

### Safety Screens

| Question | Response |
|----------|----------|
| Fall in past 24 hours? | ☐ Yes ☐ No |
| Head injury? | ☐ Yes ☐ No |
| Loss of consciousness? | ☐ Yes ☐ No |
| Recent surgery? | ☐ Yes (When: _______) ☐ No |
| Recent travel? | ☐ Yes (Where: _______) ☐ No |
| Exposure to COVID-19/illness? | ☐ Yes ☐ No |

### For Women of Childbearing Age

| Question | Response |
|----------|----------|
| Could you be pregnant? | ☐ Yes ☐ No ☐ N/A |
| Last menstrual period | |
| Currently breastfeeding? | ☐ Yes ☐ No ☐ N/A |

---

## Red Flag Assessment

**Check if ANY present (requires immediate provider notification):**

| Red Flag | Present |
|----------|---------|
| Chest pain/pressure | ☐ |
| Difficulty breathing at rest | ☐ |
| SpO2 <92% | ☐ |
| Severe headache (worst of life) | ☐ |
| Sudden vision loss | ☐ |
| Sudden weakness/numbness | ☐ |
| Speech difficulty | ☐ |
| Facial droop | ☐ |
| Uncontrolled bleeding | ☐ |
| Altered mental status | ☐ |
| Syncope | ☐ |
| Anaphylaxis symptoms | ☐ |
| Suicidal/homicidal ideation | ☐ |

**If ANY checked → Immediate provider evaluation and consider ED transfer**

---

## Acuity Level Assigned

☐ **Level 1 - Emergent** (ED Transfer Required)
   → Provider/911 notified: Time _______ Name _______

☐ **Level 2 - Urgent** (Provider within 15 min)
   → Provider notified: Time _______

☐ **Level 3 - Semi-Urgent** (Provider within 30 min)

☐ **Level 4 - Non-Urgent** (Provider within 60 min)

☐ **Level 5 - Redirect** (Outside UC scope)
   → Redirected to: _______

---

## Interventions Initiated

| Intervention | Ordered | Completed |
|--------------|---------|-----------|
| Ice pack | ☐ | ☐ |
| Elevation | ☐ | ☐ |
| Wound care | ☐ | ☐ |
| POC glucose | ☐ | ☐ |
| POC UA | ☐ | ☐ |
| POC strep | ☐ | ☐ |
| POC flu/COVID | ☐ | ☐ |
| ECG | ☐ | ☐ |
| Other: | ☐ | ☐ |

---

## Pain Assessment

| Field | Entry |
|-------|-------|
| Location | |
| Quality | ☐ Sharp ☐ Dull ☐ Aching ☐ Burning ☐ Throbbing |
| Intensity (0-10) | /10 |
| Onset | ☐ Sudden ☐ Gradual |
| Duration | |
| What relieves it? | |
| What worsens it? | |
| Previous episodes? | ☐ Yes ☐ No |

---

## Injury Details (if applicable)

| Field | Entry |
|-------|-------|
| Mechanism of Injury | |
| Time of Injury | |
| Location of Injury | |
| Tetanus status | ☐ Up to date ☐ Needs update ☐ Unknown |
| Work-related? | ☐ Yes ☐ No |

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## Additional Notes

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## Re-Triage (if waiting time extended)

| Time | Vital Signs | Condition Changed? | New Acuity | Initials |
|------|-------------|-------------------|------------|----------|
| | | ☐ Yes ☐ No | | |
| | | ☐ Yes ☐ No | | |
| | | ☐ Yes ☐ No | | |

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## Triage Nurse/MA Signature

| Field | Entry |
|-------|-------|
| Name | |
| Credentials | |
| Signature | |
| Date | |
| Time | |

---

## Provider Acknowledgment

| Field | Entry |
|-------|-------|
| Provider notified at | (time) |
| Provider seen at | (time) |
| Provider Signature | |

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*Form FRM-UC-001 Rev 1.0 - Urgent Care Triage Assessment*