Paperwork for urgent care

A note before you read

I practice internal medicine, so this page is about the kind of paperwork I think a clinician working in urgent care might need to do. What goes on the paperwork has to come from the clinician who saw the patient that day.

Work and school notes

Most of the paperwork in urgent care is short. An employer wants a note for the days the patient missed, or a school or daycare wants to know when a child can come back. A routine work note says when the patient can return and whether there are limits, such as no lifting over 20 pounds for a week, and it does not need the diagnosis. A school or daycare note should say something the school can act on, such as the days the child could not attend and the day they can come back.

A patient may ask for a note that covers days before the visit. I would write only the dates I can stand behind. If a patient says they have been sick since Monday and I see them on Wednesday, the note can say that I saw them on Wednesday and that they report being ill since Monday, rather than certify two days I did not see.

Because I may not see the patient again, I would give every limit an end date. If it might need to go on longer, the note can say who should recheck the patient before it is extended, rather than leave it open.

When the patient needs more than a note

Some patients need a longer form. Family and Medical Leave Act (FMLA) certifications, disability claim statements and workers’ compensation reports usually go to the patient’s primary care doctor or the treating specialist, who will see the patient again. If a patient brings one of these forms to urgent care, I would tell them who is likely to complete it.

An urgent care note can still help in the meantime. It can say the date you saw the patient, the days they were unable to work or attend school, the day they can go back, and any limits, each with an end date. That gives the employer or school something to act on, and it gives the doctor who completes the longer form a record of your visit.

Where PatientPapers fits

I built PatientPapers to make this paperwork easier to complete. PatientPapers walks you through the forms urgent care clinicians are asked to complete, such as return-to-work notes, work restriction letters, and school and daycare notes, so you can fill them out more quickly and more confidently. You set up your information once on each computer you use. Then you answer one question at a time, and nothing goes on the form until you confirm it. Before you sign, it flags some problems, such as family history in a work note. Then you review the completed form, and if everything looks correct, you sign it and you’re done.

Your patients’ information is encrypted on your own device with a passcode only you know, and none of it is sent to us or anyone else. Because we never receive it, there is no business associate agreement to sign with us. We cannot reset your passcode, so setup asks you to save a recovery code, and if you forget the passcode that code lets you set a new one. HIPAA still applies to how your office handles that computer, any copies you export, and the forms you print and sign. If you want to see whether it helps with your own paperwork, try the free trial, and I think you will find it saves you time and makes the forms more intuitive to complete.

Questions the office asks

Can I write a work note for days before the visit?

I would write only the dates I can stand behind. The note can say the day you saw the patient and that they report being ill since an earlier day, rather than certify days you did not see.

Does a sick note need the diagnosis?

Not a routine one. A work or school note should say when the patient can return and any limits, and until when.

Can my nurse or medical assistant fill in the form for me?

Yes. A provider can add staff such as a nurse or medical assistant, at no extra charge, and each one gets their own passcode. They can fill in the whole form and mark it ready for you, but only the certifying provider can sign it, so I would read what they entered before signing. Everything stays on one computer, so a simple setup is one laptop or tablet kept just for forms that staff and clinicians share. How staff help with forms is the practice’s to arrange and supervise.