URI Documentation Template

Overview

Upper respiratory infections (URIs) represent one of the most common reasons for urgent care visits. While clinically straightforward, documentation must clearly support the diagnosis, demonstrate appropriate clinical reasoning, and reflect the shared decision-making conversation around antibiotic stewardship. A well-documented URI note protects you medically, satisfies payer requirements, and models good practice for trainees.

HPI Example

Patient is a 28-year-old male presenting with 4 days of nasal congestion, clear rhinorrhea, mild sore throat, and low-grade subjective fevers. Reports associated dry cough and mild headache. Denies high fever (temp checked at home, maximum 99.1°F), purulent nasal discharge, facial pain or pressure, ear pain, rash, shortness of breath, chest pain, or difficulty swallowing. No known sick contacts. No recent travel. No prior episodes requiring antibiotics in the past 3 months. NKDA.

ROS Example

Constitutional: Low-grade fever, fatigue, mild myalgia. Denies chills. HEENT: Nasal congestion, clear rhinorrhea, sore throat. Denies ear pain, ear discharge, facial pressure, vision changes. Respiratory: Mild dry cough. Denies shortness of breath, wheezing. Cardiovascular: Denies chest pain, palpitations. GI: Mild decreased appetite. Denies nausea, vomiting. Neurologic: Mild frontal headache. Denies dizziness, confusion.

Physical Exam Example

Vitals: T 99.1°F, HR 82, BP 118/74, RR 16, SpO2 99% RA General: Alert, oriented x3, mild distress due to congestion, well-appearing HEENT: Normocephalic, atraumatic. TMs clear bilaterally, no erythema or effusion. Nasal turbinates mildly edematous with clear discharge. Posterior oropharynx with mild erythema, no exudate, no uvular deviation. No anterior or posterior cervical lymphadenopathy. Neck: Supple, no meningismus Respiratory: Clear to auscultation bilaterally, no wheezes, rhonchi, or rales Cardiovascular: Regular rate and rhythm, no murmurs

MDM Example

Problem: Acute URI, viral etiology Number of Diagnoses/Management Options: 1 acute uncomplicated problem - Low Amount/Complexity of Data: Minimal - clinical diagnosis; no testing ordered Risk: Low - over-the-counter medications recommended; no prescription required Overall MDM Level: Low (supports 99213 / 99283 equivalent) Clinical decision-making: Presentation is consistent with viral URI. No features to suggest bacterial sinusitis (>10 days, biphasic course, focal facial pain), streptococcal pharyngitis (no exudate, Centor score 0–1), or influenza (not indicated by season). Antibiotics not indicated; patient counseled on viral etiology, expected 7–10 day course, and antibiotic stewardship. Return precautions discussed in detail.

Smart Phrase

.URI HPI: Patient presents with [X] days of nasal congestion, [clear/purulent] rhinorrhea, [sore throat/without sore throat], and low-grade [fever/subjective fevers]. [Associated dry cough / No cough.] Denies difficulty breathing, chest pain, ear pain, or rash. No sick contacts reported. Exam: Vitals stable. Nasal turbinates [edematous/clear]. TMs clear bilaterally. Oropharynx [mild erythema/WNL], no exudate. Lungs CTA bilaterally. A/P: Acute URI, viral etiology. Symptomatic management. Patient educated on viral course (7–10 days) and antibiotic stewardship. Return precautions given - return for fever >72h, worsening symptoms, SOB, or severe headache.

Documentation Tips

• Document that you specifically evaluated for strep even if you didn't test - note Centor criteria or the absence of exudate and fever pattern.
• For Low MDM, your decision-making must still appear in the chart. Note explicitly that you counseled on antibiotic stewardship.
• If prescribing decongestants, document the indication and your contraindication check (hypertension, BPH, pregnancy).
• Documenting the 'negative decision' - why you did NOT order a strep test or flu swab - is as important as documenting what you did order.

Related Documentation Guides

• Chest Pain Documentation Example
• Sports Physical Documentation Template