ED template - Chris

ID

[patient's age and sex, followed by a comma, followed by 'presents with' and their chief complaint] (see contextual notes for other information that must be included here)

HPI

[history of presenting illness in line-by-line format.] (Tell the patient's story in a narrative format. Include all pertinent positives and negatives that were explicitly mentioned. In a separate paragraph, list any review-of-systems elements that were explicitly mentioned. Also, in a separate paragraph, include other information about the patient that does not fit into any other section of the note.)

PMHx

[Past medical history organized in a numbered list with a separate line for each diagnosis.] (include any details that were explicitly mentioned. If past medical history was listed in the Context tab, you must include everything there.)

SocHx

[Social history.] (include information such as: Who the patient lives with, Where they live, Whether the patient uses a cane or walker or other mobility aid, whether they receive home care, details of alcohol use, Details of smoking history, and Details of other substance use. Use 1 line for each item. Omit this section if not explicitly mentioned).

MEDICATIONS/ALLERGIES

[Numbered list of medications.] (if mentioned in the context tab, include everything listed there. If no medications, write 'No usual medications.') [numbered list of allergies under the heading 'Allergies:', with a separate line for each allergy] (Include the reaction if explicitly mentioned. If not explicitly mentioned, state that the reaction is unknown. Include when the reaction occurred and the details, if explicitly mentioned. If allergies are not explicitly mentioned, omit this section)

Chief Complaint

ED template

EXAM

[results of physical exam] (include each system on a separate line mention any positive findings along with normal exam findings. If system not assessed, include normal exam findings as below.) For Example: Vital signs were noted. The patient was well-appearing, in no distress. CVS: heart sounds normal. No murmurs. Good peripheral pulses. No edema. No signs of DVT. Resp: good air entry bilaterally. No focal findings. No adventitious sounds. No prolonged expiratory phase. MSK/Skin: There is a two-centimeter oblique laceration located over the left patella. No deeper structures are affected by the laceration. There is no numbness when the area is touched. There are no signs of infection such as increased warmth, erythema, pain, or purulent discharge. The wound edges approximate well with knee flexion and extension. Mild bleeding is present but not concerning. Motor Exam: Normal motor function in the left lower extremity. Abdominal Exam: soft. Non tender. No masses. No hernias. No CVA tenderness. Neuro Exam: Cranial nerves grossly intact. Using all 4 limbs symmetrically. No abnormality in speech or gait noted while in ED.

Investigations

[point of care ultrasound results] (if bedside ultrasound was not mentioned, omit this section)[investigation results, if explicitly mentioned]

COURSE IN ED

[events during the patient's emergency department stay.] (include fluid and medications administered, if explicitly mentioned. Include changes in status and results of re-assessment, if explicitly mentioned. If nothing explicitly mentioned, write 'Stable.')

ASSESSMENT

[the most likely primary diagnosis, if one was explicitly mentioned.] (if no specific primary diagnosis was mentioned as most likely, use the main symptom.) [include any secondary diagnoses, or important medical issues, that were discussed during this visit] (put each one on its own line. If no additional diagnoses or issues were identified, omit this part)

PLAN

[the assessment and plan] (summarize the differential diagnosis that was considered and which diagnoses were ruled out, if explicitly mentioned. Include the working diagnosis, if explicitly mentioned. Include what advice the patient was explicitly given. Include what return to care instructions the patient was explicitly given. Include follow advice or arrangements if this was explicitly mentioned. Finish with the words 'The patient was happy with this plan.')