AI Scribe for Urgent Care
Transcribe Health drafts the note while you see the next walk-in, so the acute complaint, exam, and disposition are on the page before the room turns over.
Photo: Fotos / Unsplash
Urgent care documentation, from triage to disposition
Urgent care lives on volume and variety. You might see a strep throat, an ankle sprain, a work injury, and a finger laceration back to back, and each one needs a focused history, a targeted exam, and a plan. The visits are short, so the pressure is to chart them fast without leaving gaps that come back at coding time.
A lot of the work is procedural. Laceration repair with a wound description, anesthetic, closure type, and suture count. Splinting a sprain or a fracture with the position and the neurovascular check. Incision and drainage of an abscess. Each of these needs a note precise enough to bill and to hand off if the patient follows up somewhere else. Dictating them at the end of a shift is where detail gets lost.
Transcribe Health listens to the visit, or to your narration during a procedure, and drafts the note with the acute complaint, the exam findings, the workup you ordered, and the disposition. It captures the return precautions you actually said out loud. You read it and sign. Nothing is filed without you.
Documentation Challenges in Urgent Care
- 1
Keeping up with walk-in throughput when the waiting room fills faster than you can chart the last patient
- 2
Capturing a wide range of acute complaints in one shift, from sore throats and sprains to lacerations and rashes, each with its own exam and workup
- 3
Writing the disposition and return precautions clearly enough that a patient sent home knows exactly when to come back or go to the ED
How Transcribe Health Helps Urgent Care
Fast Acute Visit Notes
Drafts the HPI, exam, and plan from the visit so you can close the chart and move to the next room without dictating later.
Procedure Documentation
Structures a note for a laceration repair, a splint, or an incision and drainage from what you narrate at the bedside.
Disposition and Return Precautions
Records the disposition, discharge instructions, and the specific return precautions you gave, so nothing gets dropped when the shift is busy.
An urgent care note, captured in real time
An abridged note from a common walk-in, a finger laceration repaired in the room, drafted the way you would see it before signing.
34-year-old man presents with a cut to the left index finger sustained about two hours ago while slicing vegetables with a kitchen knife. Bleeding controlled with direct pressure at home. Denies numbness, and reports he can bend and straighten the finger normally. No foreign body sensation. Last tetanus booster more than 10 years ago. No blood thinners, no diabetes.
Afebrile, vitals stable. Left index finger with a 2 cm linear laceration over the volar aspect of the proximal phalanx. Wound edges clean, no active bleeding, no visible tendon or bone, no foreign body on inspection. Capillary refill less than 2 seconds, sensation intact to light touch on both sides of the finger, full flexion and extension at the DIP and PIP joints.
1) Laceration of left index finger without tendon, nerve, or vascular injury. 2) Tetanus immunization not up to date.
Wound irrigated with normal saline. Local anesthesia with 1% lidocaine. Simple repair with three interrupted 4-0 nylon sutures, wound edges well approximated. Tdap administered in the left deltoid. Bacitracin, non-adherent dressing, and a fingertip bandage applied. Discharged home with wound care instructions: keep clean and dry for 24 hours, then may wash gently. Return in 10 days for suture removal, or sooner if increasing redness, swelling, pus, red streaking, fever, or numbness. Advised to go to the ED for uncontrolled bleeding or loss of movement.
Illustrative example. Not a real patient encounter.
Built for urgent care coding and your EMR
Notes capture the history, exam, and workup behind your E/M level, and the wound length, repair type, and site that a procedure code needs. That is the detail that gets rushed when the board is full, and the first thing a payer looks for.
- 99213Established-patient visit, low to moderate complexity
- 99214Established-patient visit, moderate complexity
- 12001Simple repair of superficial wound, 2.5 cm or less
- 12002Simple repair of superficial wound, 2.6 cm to 7.5 cm
- 87880Rapid strep test, direct group A strep antigen
- 29125Application of short arm static splint, forearm to hand
- S61.411ALaceration without foreign body of right index finger, initial encounter
- J02.9Acute pharyngitis, unspecified
- S93.401ASprain of unspecified ligament of right ankle, initial encounter
- J06.9Acute upper respiratory infection, unspecified
- S01.00XAUnspecified open wound of scalp, initial encounter
Fits the workflow you already have
Drafts drop into the systems urgent care clinics run on, including Experity (formerly DocuTAP and Practice Velocity), Epic, Oracle Health (Cerner), and athenahealth. You get the note type you are working in, a quick acute visit or a procedure note. It writes up the wound description, closure, and discharge instructions you dictate. It does not order labs or pull results on its own; you review the rapid strep or X-ray and it records your read.
Urgent care AI scribe questions
Can it keep up with our patient volume?
Does it handle procedures like laceration repair and splinting?
Will it capture return precautions and discharge instructions?
Does it help with coding?
How is patient information protected?
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