ED Visit Template - Modified Specialist Consult

Introduction

ED Staff Note ID: [patient_name] presented to the Emergency Department on [date] [Specific complaint or reason for the visit (only include if applicable), according to Chief Complaint]. See chart for time seen (always say)

Chief Complaint

All complaints

History of Present Illness

[Detailed description including onset, duration, character, and associated symptoms, past investigations and previous physicians seen or treatments tried (please include details, quotes, examples). This can briefly include relevant past medical history, including details on chronic conditions, previous illnesses, and surgeries (please list per chronic condition). This can also briefly include relevant Family and Social History, for example, The patient lives with [living situation, please note names, ages and genders of siblings and any pets]. Details on home environment, education and employment, social activities, drugs, sexuality, dietary habits, exercise routines. Include relevant health information about the patient's spouse or partner if applicable. Hereditary conditions or diseases within the family especially those related to the history of presenting illness (please list the family health history in bullets)].

Past medical and surgical history

include relevant past medical history, including details on chronic conditions, previous illnesses, and surgeries (please list per chronic condition).

Current Medications

[List of current medications and dosages in bullet form (only include if applicable, if there are none please write "none")]

Allergies

[Specific allergies, especially to medications (if not mentioned leave section out, if no allergies please write "none")]

Observations

[Any notes about the patient's general appearance, mental status, interactions, and physical activities (if there is a conversation with the patient, please include quotes)]

Vital Signs

Blood Pressure [blood pressure] | Temp [temperature] | HR [heart rate] | RR [respiratory rate] | O2 [oxygen saturation] | Pain Level [pain level] (only include if mentioned)

Physical Exams

Please format the vital signs as follows: Blood Pressure [blood pressure] | Temp [temperature] | HR [heart rate] | RR [respiratory rate] | O2 [oxygen saturation] | [Brief notes on HEENT, Chest/Lungs, Cardiovascular, Abdomen, Musculoskeletal, Neurological, and Skin (only include findings if mentioned, if not mentioned please leave blank)] [Specialized sections per specialty, such as obstetrical history for ObGyn or joint exam detail for Orthopedics, should be included if applicable.]

Investigations

[Description and date of any investigations or laboratory results (if there are no investigations mentioned please write "none relevant") use abbreviations for investigations] Urinalysis: Glucose [glucose] | Protein [protein] | SG [specific gravity] | pH [pH] | Nitrates [nitrates] | Leukocytes [leukocytes] | CBC : WBC [leukocytes] | HgB [hemoglobin] | PLT [platelets] | Chemistry: Na [sodium] | Cl [chloride] | K [potassium] | Glucose [glucose] | Creatinine [creatinine] | eGFR [eGFR if given] | CRP [c reactive protein] | Albumin [albumin if given] | LFTs: Alk [alk phos] | ALT [ALT] | total bili [total bilirubin] | Lipase [lipase] | PT [] | INR [] | PoCUS/point of care ultrasound/bedside ultrasound: detail results verbatim (if there are no ultrasound mentioned please write "none relevant") When displaying the results of investigations use the following format Urinalysis: Glucose [glucose] | Protein [protein] | SG [specific gravity] | pH [pH] | Nitrates [nitrates] | Leukocytes [leukocytes] | CBC : WBC [leukocytes] | HgB [hemoglobin] | PLT [platelets] | Chemistry: Na [sodium] | Cl [chloride] | K [potassium] | Glucose [glucose] | Creatinine [creatinine] | eGFR [eGFR if given] | CRP [c reactive protein] | Albumin [albumin if given] | LFTs: Alk [alk phos] | ALT [ALT] | total bili [total bilirubin] | Lipase [lipase] | PT [] | INR [] | Eliminate any blank lines in formatting Only display bloodwork results or urine results that were dictated or given. Do not display the [] around the numbers.

Procedures

[Detail any medical procedures performed during the encounter, including the purpose, methods, and outcomes. If no procedures were performed or mentioned, please write "none"]

Assessment

[Should include the consulting physician’s impression and analysis of the history, physical examination, and investigation findings and a discussion around the critical reasoning for how they have reached their conclusions. Should answer the referring physician’s question.]

Assessment

[Should include the consulting physician’s impression and analysis of the history, physical examination, and investigation findings and a discussion around the critical reasoning for how they have reached their conclusions. Should answer the referring physician’s question.]

Diagnosis

[Should include the consulting physician’s impression and analysis of the history, physical examination, and investigation findings. Summarize the critical reasoning for how the diagnosis was obtained. If explicitly mentioned, include the diagnostic conclusion here.]

Plan and Recommendations

[Please list each issue or diagnosis by number and with each issue, and following each issue include a plan relevant to that issue] [Diagnosis or diagnostic impression of the patient's condition (only include if explicitly mentioned), any discussion and explanation given to the patient about the disease or condition or symptoms consistent with the diagnostic impression, summary of key findings (only include if applicable)], [Differential diagnoses (only include if applicable)], [Recommendations for treatment, management, medications, referrals or involvement of other professionals, investigations. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]

Follow-Up

[Conclude with any additional recommendations or follow-up instructions explicitly mentioned during the encounter. For example: "The patient was advised to return to the Emergency Department if.] [Specify under what conditions to return earlier (only include if applicable)]