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 |
|
|
|
|
|
|
|
|
|
|
|
|
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 |
| Onset: When did this start? |
|
| Provocation: What makes it better/worse? |
|
| Quality: Describe the symptom |
|
| Radiation: Does it travel anywhere? |
|
| Severity: How bad is it (0-10)? |
|
| Timing: 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 |
Additional Notes
Re-Triage (if waiting time extended)
| Time |
Vital Signs |
Condition Changed? |
New Acuity |
Initials |
|
|
☐ Yes ☐ No |
|
|
|
|
☐ Yes ☐ No |
|
|
|
|
☐ Yes ☐ No |
|
|
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 |
|
Form FRM-UC-001 Rev 1.0 - Urgent Care Triage Assessment
