Emerg Note Template

Chief Complaint

New Level 2/3 Emerg Note

History of Present Illness

[Be extremely detailed. Clearly document all symptoms, relevant history, and details about current medical symptoms. Be specific about their duration, nature, severity, exacerbating and alleviating factors (Write it in bullet points for clarity).] (Have each concern as a numbered list format)

The Review of Systems

[Document a system-by-system review of symptoms the patient is experiencing, Include all pertinent positives and negatives. Do NOT repeat symptoms that are described in the History of Present Illness. Do NOT include physical exam findings. Do NOT create symptoms that were not discussed.]

Past Medical History

[Include all significant medical conditions with dates if available, hospitalizations, major illnesses, surgeries, and any chronic conditions, clearly separated from HPI. Use a bullet point list. Use medical terminology with appropriate abbreviations. Include past surgical history in this section.] Example: • essential tremor • No history of hypertension • No history of diabetes mellitus • No history of hypercholesterolemia

Medications

[Detailed list of current medications and dosages, ensuring they are extracted from the HPI and listed separately.] • [Medication 1] [Dosage & Frequency if mentioned] • [Medication 2] [Dosage & Frequency if mentioned] ...

Family History

[If mentioned. Include significant medical conditions in first-degree relatives, e.g., diabetes, hypertension, heart disease, genetic disorders. Do NOT include if not mentioned.] (Use bullet point for clarify)

Social History

[Detailed information on the patient’s lifestyle including substance use, occupation, living situation, mobility, activities of daily living, hand dominance, and any relevant social factors.] (Use bullet point for clarify)

MOST

[If mentioned, document the patient’s code status (e.g., C2, C1, C0, M3, M2, M1) and any discussion about code status.]

Vital Signs

[Include blood pressure, heart rate, respiratory rate, temperature, weight, height, BMI, glucose. If nothing said, put "As per electronic triage."]

Physical Examination

[Provide a detailed narrative of the physical examination findings. Include the following sections only when mentioned: General, ENT, Chest, CVS, Abdomen, Neuro, MSK, and ECG and any other examination mentioned. For each section, describe the observations and any notable findings in details and use medical terminology. Use bullet point style for each exam to maintain consistency and clarity] Example: General: She is alert and oriented. Glasgow Coma Scale is 15. ENT: Pupils are equal, round, and reactive to light at 3 millimeters. Oropharynx is normal. Chest: Good air entry bilaterally, no increased work of breathing, no crackles or wheezes. CVS: Heart sounds are normal with S1 and S2. No S3 or S4. No murmurs. Peripheral pulses are present and palpable in all four extremities. No leg swelling or tenderness. Abd: Abdomen is soft with mild tenderness in the mid-abdomen. No rebound or guarding. No costovertebral angle tenderness. Neuro: Cranial nerves III through XII are intact. Strength is 5/5 in all four extremities. Sensation to light touch is normal. No pronator drift. Finger-to-nose testing is normal. Normal gait MSK: No abnormalities noted. Range of motion and strength are preserved in all extremities. ECG: She demonstrates normal sinus rhythm without significant changes compared to previous tracings.

Assessment

[List each diagnosis or problem with corresponding medical codes. For each, provide a brief summary including clinical features and differential diagnoses (DDx). Use the following format:] [Number]. [Diagnosis] ([Code]): [Brief description of the condition and clinical presentation.] - DDx: • [Differential diagnosis 1 with rationale.] • [Differential diagnosis 2 with rationale.] [Repeat for each diagnosis or problem.] Example: 1. Right Shoulder Osteoarthritis (715.91): Chronic degenerative joint disease causing stiffness and pain in the right shoulder. - DDx: • Osteoarthritis: Supported by radiographic findings and clinical presentation. 2. Shortness of Breath with Positional Chest Pain (786.05): Dyspnea worsened when lying flat, accompanied by chest pain on twisting movements. - DDx: • Cardiac dysfunction: History of myocardial infarction and stent placement suggests possible cardiac etiology. • Pulmonary causes: Less likely given clear lung examination and absence of cough or sputum. 3. Left Breast Cyst (611.72): Enlarged, painful cyst located in the left upper outer quadrant of the breast. - DDx: • Breast cyst: Clinical findings and patient report of increased size and tenderness. 4. History of Sigmoid Colectomy and Polyp Removal (V45.89): Surveillance for colorectal cancer risk following prior surgery and polyp removal. - DDx: • Post-polypectomy surveillance. 5. Mental Health Disorders (unspecified): Patient currently on venlafaxine, quetiapine, and risperdal. - DDx: • Depression and/or anxiety: Managed with current pharmacotherapy. 6. Sleep Disturbance and Fatigue: Poor sleep quality with patient sleeping propped up due to shortness of breath. - DDx: • Possible cardiac or respiratory causes contributing to sleep disturbance.

Assessment

[List each diagnosis or problem with corresponding medical codes. For each, provide a brief summary including clinical features and differential diagnoses (DDx). Use the following format:] [Number]. [Diagnosis] ([Code]): [Brief description of the condition and clinical presentation.] - DDx: • [Differential diagnosis 1 with rationale.] • [Differential diagnosis 2 with rationale.] [Repeat for each diagnosis or problem.] Example: 1. Right Shoulder Osteoarthritis (715.91): Chronic degenerative joint disease causing stiffness and pain in the right shoulder. - DDx: • Osteoarthritis: Supported by radiographic findings and clinical presentation. 2. Shortness of Breath with Positional Chest Pain (786.05): Dyspnea worsened when lying flat, accompanied by chest pain on twisting movements. - DDx: • Cardiac dysfunction: History of myocardial infarction and stent placement suggests possible cardiac etiology. • Pulmonary causes: Less likely given clear lung examination and absence of cough or sputum. 3. Left Breast Cyst (611.72): Enlarged, painful cyst located in the left upper outer quadrant of the breast. - DDx: • Breast cyst: Clinical findings and patient report of increased size and tenderness. 4. History of Sigmoid Colectomy and Polyp Removal (V45.89): Surveillance for colorectal cancer risk following prior surgery and polyp removal. - DDx: • Post-polypectomy surveillance. 5. Mental Health Disorders (unspecified): Patient currently on venlafaxine, quetiapine, and risperdal. - DDx: • Depression and/or anxiety: Managed with current pharmacotherapy. 6. Sleep Disturbance and Fatigue: Poor sleep quality with patient sleeping propped up due to shortness of breath. - DDx: • Possible cardiac or respiratory causes contributing to sleep disturbance.

Plan

[For each diagnosis or problem, Provide a detailed narrative that outlines the management plan, including investigations, referrals, treatments, patient education, and follow-up.(Have each diagnosis as a numbered list format, and corresponding plan in bullet point)] Example: 1. [Problem 1]: - [Recommended treatment and management plan] - [Referral details and further assessment plans] - [Patient education and lifestyle modifications] - [Follow up & referral details] - [Other] 2. [Problem 2]: - [Recommended treatment and management plan] - [Referral details and further assessment plans] - [Patient education and lifestyle modifications] - [Follow up & referral details] - [Other]

Plan

[For each diagnosis or problem, Provide a detailed narrative that outlines the management plan, including investigations, referrals, treatments, patient education, and follow-up.(Have each diagnosis as a numbered list format, and corresponding plan in bullet point)] Example: 1. [Problem 1]: - [Recommended treatment and management plan] - [Referral details and further assessment plans] - [Patient education and lifestyle modifications] - [Follow up & referral details] - [Other] 2. [Problem 2]: - [Recommended treatment and management plan] - [Referral details and further assessment plans] - [Patient education and lifestyle modifications] - [Follow up & referral details] - [Other]

Reassessment Note

[Reassessment plans. (in bullet point). Alway include this heading, even if not mentioned.]

Disposition

[[If mentioned, generate patient Education and follow up as instructed below, otherwise state N/A] Patient Education: [Discuss educational points provided to the patient’s caregivers, such as lifestyle modifications, disease-specific information] Follow Up: [Include follow-up appointments, monitoring plans]]

Consent

This note was created with the assistance of an PIPEDA compliant AI scribe after verbal consent from the patient or their proxy. All notes are reviewed and edited for accuracy and completeness prior to being signed in the EMR.]