Alex's ER Visit- Concise FHA with RA

ASSESSMENT TIME

[State the time of assessment in military time in Pacific Standard Time. If no time is dictated by me, list the time that recording for this patient began, ie: 1805h]

REFERRING MD

[Omit section if no referring MD mentioned. Referring MD can never be Dr. Alexander Suleiman]

REASON FOR REFERRAL

[ONLY If mentioned, state the reason for referral by the referring physician. Keep it brief.]

CHIEF COMPLAINT

[Document the patient's primary complaint, including the duration and any relevant details.] For example: Lower abdominal pain for one day.

HISTORY OF PRESENT ILLNESS

[If it is explicitly stated that this is a referral from another physician or nurse practitioner, state when the patient was seen by the referrer. Indicate that the referring clinician sent the patient in for emergency consultation and for what reason, (ie: Patient was seen by his family physician in telehealth and instructed to present to the ER for urgent workup of his abdominal pain)] [Provide bullet points of the patient's current illness, including onset, duration, symptoms, and any relevant triggers or associated factors. In a concise format and Use as many abbreviations as possible]. If mentioned, include a brief review of systems at the end. Ie: No fever, no URTI, no chest pain or urinary symptoms

PAST MEDICAL HISTORY

[List the patient's past medical history in a very concise format with only few words, and numbered format.] For example: 1. [Condition 1] 2. [Condition 2] ... n. [Condition n]

MEDICATION (INCLUDING ALLERGIES)

[List the patient's current medications and any known allergies in a list. If no Allergies, state "NKDA"] Example: [Medication/Allergies 1] [Medication/Allergies 2]

PHYSICAL EXAMINATIONS

GENERAL: [Provide a concise assessment of the patient's general appearance in bullet points, including ability to ambulate, and skin color.] HEART: [Provide concise findings of the heart examination, including pulse regularity, JVP status, heart sounds, and presence or absence of murmurs. Use bullet points for each finding.] ABDOMEN: [Provide concise findings of the abdominal examination, including inspection, auscultation, and palpation results. Use bullet points to list observations such as surgical wounds, distension, ascites, bowel sounds, tenderness, hepatosplenomegaly, pulsatile masses, Murphy sign, McBurney Point tenderness, and hernia evidence.] [List any other exams mentioned and their corresponding finding under. If a system or heading is not included in the transcript, remove that heading or section.] - [avoid colloquial language and lay-speech, even if those words are used by the physician. Use proper medical terminology instead, for example: "funny heart rhythm" becomes "arrythmia]

INVESTIGATIONS (INCLUDING ORDERS/RESULTS)

[List the investigations performed, their results, and any relevant orders. Use as many as abbreviation as possible] For example: - CBCs normal, CRP [Value] - Renal function is normal, liver function is normal. - Urine shows [Findings].

ER TREATMENT

(Do not use lay speech used with patients, example: "No special medicine needed" should be mapped to medical terminology such as, "Patient was informed no medical intervention is needed") [Discuss with the patient the following points:] [Write it in very concise format] - [Patient's problem, including diagnosis and relevant findings.] - [Treatment options, including medications and any specific instructions.] - [Results of any tests conducted, highlighting significant findings.] - [Patient's concerns or additional medical history relevant to the current condition.] - [Recommendations from the attending physician, including any follow-up actions.] - [Patient's decision regarding admission or discharge, including conditions for returning to the ER.] - [avoid colloquial language and lay-speech, even if those words are used by the physician. Use proper medical terminology instead, for example: "funny heart rhythm" becomes "arrythmia]

Referring MD

PRIMARY ER DIAGNOSIS

[Document the primary diagnosis made in the ER. In a list format] [for each item include the ICD9 code] For example: Subacute SBO Acute coronary syndrome with triple vessel disease - [Under each item, include a brief summary of clinical reasoning for why a diagnosis is favored, as well as alternate diagnoses which are not favored. If any clinical decision making tools are mentioned, ie PERC or HEART score, include that commentary here.] - [avoid colloquial language and lay-speech, even if those words are used by the physician. Use proper medical terminology instead, for example: "funny heart rhythm" becomes "arrythmia]

DISPOSITION AND MANAGEMENT PLAN

[Specify the patient's disposition in very concise format and use as many abbreviations as possible, such as home or hospital admission. Include follow-up instructions with a specific timeframe if applicable, e.g., "Follow up in 24 hours if no improvement." or "Review any outstanding test results with family physician or urgent care". Include any commentary on decision making, ie "given the systemic features including fevers and chills, the patient will be placed on IV antibiotics". When a decision is made with reasoning, cite the reasoning. Write it in list format] Example: - Admit under internal medicine for monitoring - FU 24 hours if no improvement - [avoid colloquial language and lay-speech, even if those words are used by the physician. Use proper medical terminology instead, for example: "funny heart rhythm" becomes "arrythmia]

MEDICATIONS & MANAGEMENT

[For each medication, provide the name, dosage, frequency, route of administration, and duration of treatment. Use a numeric list format to maintain consistency with the input content. Write it in a very concise format and use as many abbreviations as possible] Example: 1. Fleet enema 2. Zofran 4 mg TDS SL for four days

REASSESSMENT

[Only include this section if I state that the patient is reassessed. If mentioned, specify the time of the reassessment in military time format. The reassessment note must include any clinical changes. If there are no changes noted, state that the symptoms have been stable. Note any response to treatment (e.g., "Pain improved with analgesia, passed walk test"). State the disposition plan, as supported by the clinical information noted in the reassessment. Note specifically if the patient is admitted or if they can be safely discharged.]