ER Template Version 1

OVERALL_INSTRUCTIONS

[if not mentioned do not include][remove pronouns] [insert finding only if mentioned. If not mentioned do not include]. [If normal write "normal"][do not include John smith in the initial history presentation]] [do not include Jane doe in the initial history presentation]

Chief Complaint

Consult Letter Template

Template

ID/CC: [Patient name] is a [Age] [Male/Female] who presents to the Emergency [accompanied by family members/spouse/friends] with [Reason of visit][do not include past medical history] History of Present Illness: [[Provide highly detailed bullet point notes of the patient's current illness in high detail, including onset, duration, symptoms, specific location of the symptom, and any relevant triggers or associated factors.] [Include ROS information and any other relevant information when mentioned, including all positives and negatives asked about. Pay special attention to duration of symptoms, progression, and do not use the word "denies" for negative symptoms, but rather "no". Do not use "states" or "reports" for positive symptoms, rather just list them. If patient says "excruciating" use "severe", if patient has ongoing or persistent symptoms, use "ongoing"; replace "persistent" with ongoing. Omit past medical/surgical history, substance use history, medication list from HPI]. [Include ALL questions that I ask that start with "have you ever had" or "do you have"] [Include all information about sign/symptoms of PE if mention which include leg swelling or pain, hemoptysis, history of VTE, when I asked]. Include any provoking factors for PE which include recent immobilization or travel, recent trauma or hospitalization, hormone use, cancer treatment] past Medical History [insert "none" if applicable]: - [diagnosis_1] - [diagnosis_2] - [diagnosis_3] Medications [insert "none" if applicable]: - [medication_name] [dose] [frequency] [route] - [medication_name] [dose] [frequency] [route] - [medication_name] [dose] [frequency] [route] Social History: [Any relevant social factors, including smoking, alcohol, drug use, occupation, the patient's current living situation, such as from home, long-term care, or assisted living, if they are independant with ADLs and iADLs, if they receive home supports or family assistance.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise, omit completely) Physical Examination: [If mentioned, include Physical Examination_details] - Vitals: [if explicitly mentioned, Temp, RR, HR, BP, O2 sat] [vital_sign within normal limits] - General Appearance: [put "looks well, NAD" unless otherwise stated] - Cardiovascular: [if I say "your heart sounds good", then document: "normal S1, S2. No extra heart sounds or murmurs. omit "jugular venous distension" unless mentioned] - Respiratory: ["if I say "your lungs sounds clear", then document: "good air entry bilaterally, no adventitious sounds] - Abdomen: ["if I say 'your abdomen is soft' or 'your belly is soft', then document "soft, nontender x 4 quadrants, no rebound tenderness or guarding, no CVA tenderness". Omit "no evidence of hernia; no ascites" unless mentioned] - Legs: [insert finding only if mentioned. If not mentioned, omit from note. If normal, write "normal"] - Neurological: [exam_finding only if mentioned. If not mentioned, omit. If mentioned and normal, insert the following (have each on an individual line under neurological exam): CN II-XII N Pupils round, equal, reactive. Visual field testing is normal No drift. Finger-to-nose N. Strong x 4 Tone N, sensation N Gait N, tandem gait N - Visual exam [insert the following if HPI indicates an ocular exam would be warranted (have each on an individual line under visual exam): Visual Acuity: Ophthalmic pressures: Slit lamp: Normal Fluorescein: [insert mentioned finding] EOM: Normal Visual Fields: Normal Head and Neck Exam: [If mentioned, include Head and Neck Exam _details] Procedures: [If mentioned, include procedure_details] Investigation results: [If mentioned, include Investigation results_details] -blood work [bloodwork results] -ecg [ecg findings] -imaging results [ xray, ct results, ultrasound results] Impression and Plan: [ONLY information that I have included] 1. [diagnosis] - Discussed with [specialist_name], advised [plan]. - Incidental Findings: [finding_1], [finding_2], [finding_3]. - Recommendations: [recommendation_1], [recommendation_2]. Patient Instructions: [Provide a detailed explanation of the patient's current condition and potential causes. Include any diagnostic tests ordered, such as MRI or EEG, and specify the purpose of these tests. Mention any medications prescribed, including dosage and frequency. Detail any specialist referrals made, including the urgency and the specialist's name. Include instructions for the patient on what symptoms to monitor and when to seek emergency care. If there are incidental findings, describe them and the recommended follow-up actions. Include any additional advice regarding ongoing treatments, such as consulting with other healthcare providers.]