ER Template - Dr.Jacky Sia

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

[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] For example: - ally if she eats something 'wrong', then she will have repeated vomiting - cramping abdominal pain. - Starting yesterday, she has intermittent abdominal pain, with nausea and - vomiting. Not able to drink water. - No fever, no URTI, no RN, 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 "NONE allergy"] Example: [Medication/Allergies 1] [Medication/Allergies 2]

GENERAL

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]

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 & REASSESSMENT

[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.]

PRIMARY ER DIAGNOSIS

[Document the primary diagnosis made in the ER. In a list format] For example: Subacute SBO Acute coronary syndrome with triple vessel disease

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." Write it in list format] Example: - Admit under internal medicine for monitoring - FU 24 hours if no improvement

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