ER Visit - General Template

Chief Complaint

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. Organize with information specific to the issue higher on the list and more general review of system information lower on the list] 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

Current Medications

[List all current medications the patient is taking, including drug names and any relevant details. Bullet list form, grouping medications if possible by disease, and listing supplements at the bottom if any] For example: - [Metformin 1000mg BID] - [Empagliflozin 25mg QD] - [Atorvastatin 20mg QD] - [Citalopram 20mg QD] - [Quetiapine 25mg QHS] - [B12 1000mcg QD] - [Multivitamin 1 tab QD]

Past Medical/Surgical History

[List the patient's past medical and surgical history in a very concise format with only few words and no repetition (group if things are similar).] For example: - [Condition 1] - [Condition 2] ... n. [Condition n]

Social History

[List the patient's social history in a concise format using a numbered list. Include only the relevant information as follows.] - Occupation - [If mentioned] - Tobacco - [Smoking History] - EtOH - [Alcohol use amount and history] - Drugs - [Any illicit drug use, if no history of such, write none] - [Housing and any other social history information]

Physical Examination

GENERAL: Vitals: [Comment on vitals if mentioned. If not, state "VSSA"] [Provide a concise assessment of the patient's general appearance in bullet points, including ability to ambulate, any sounds or signs of distress, or appearance of cyanosis, pallor, or diaphoresis.] CARDIAC: [Only if mentioned] [Provide concise findings of the heart examination, including pulse regularity, JVP status, heart sounds, and presence or absence of murmurs. If all normal, document as "RRR, normal S1/S2. No heaves, murmurs, or thrills".] RESPIRATORY: [Only if mentioned] [Provide concise findings of the respiratory examination, including bilateral expansion, midline trachea, difficulty breathing, appearance of tachypnea. If all normal, document as "Clear to auscultation, GAEB. Speaking in full sentences, no accessory muscle use. No increased WOB"] ABDOMEN: [Only if mentioned, if not, remove heading] [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. If all normal, document as "Soft, BS +. Non-tender in all quadrants. No peritoneal signs. No organomegally or masses. ] [List any other exams mentioned and their corresponding finding under] [This section should only ever include physical findings, never document any information given by the patient in this section. For example if there was no loss of consciousness reported by the patient, that does not go under this section but under the Subjective section.]

Investigations

[List the investigations performed and their results. Use as many as abbreviation as possible. If there was nothing ordered or motioned, remove this section completely. Group labs where it makes sense.] For example: - CBCs normal, CRP [Value] - Renal function is normal, liver function is normal. - Urine shows [Findings].

Assessment and Plan

ID: [Give a concise 1-2 line overview of the reason the patient was here and the findings] [For each diagnosis, provide the diagnosis name and code, a brief assessment of the patient's status, and a clear plan including medication changes, follow-up instructions, or further evaluations. Use numbered format for multiple diagnoses. If the diagnosis is not definite or obvious, add a differential diagnosis that was discussed or that would make sense for the symptoms and reasons which each one is more or less likely] Example: 1. [Diagnosis Name] ([Code]): [Brief assessment.] Plan: - [Plan details] 2. [Diagnosis Name] ([Code]): [Brief assessment.] Plan: - [Plan details] [Create 'Return to ED instructions' specific to the diagnosis (for example if a head injury, write vomiting more than 3 times or acute altered mental status or any other signs of intracranial hemorrhage) as well as 'if symptoms worsen or any concerns' as well as create when to follow-up with their GP (usually 3-5 days) for reassessment as needed.]

Assessment and Plan

ID: [Give a concise 1-2 line overview of the reason the patient was here and the findings] [For each diagnosis, provide the diagnosis name and code, a brief assessment of the patient's status, and a clear plan including medication changes, follow-up instructions, or further evaluations. Use numbered format for multiple diagnoses. If the diagnosis is not definite or obvious, add a differential diagnosis that was discussed or that would make sense for the symptoms and reasons which each one is more or less likely] Example: 1. [Diagnosis Name] ([Code]): [Brief assessment.] Plan: - [Plan details] 2. [Diagnosis Name] ([Code]): [Brief assessment.] Plan: - [Plan details] [Create 'Return to ED instructions' specific to the diagnosis (for example if a head injury, write vomiting more than 3 times or acute altered mental status or any other signs of intracranial hemorrhage) as well as 'if symptoms worsen or any concerns' as well as create when to follow-up with their GP (usually 3-5 days) for reassessment as needed.]