ER YZ - Snider

Chief Complaint

[ER General Note]

History of Present Illness

[This should be very brief - this is for our minor patient track] {ER_mode: Only generate content for ROS, vitals & PE sections that are explicitly discussed in the transcript of patient-doctor dialogues 1. Omit any system that is not mentioned or assessed 2. Do not add any additional systems or information not specified in this template 3. Each system assessment must start on a new line} [age] years old [gender] with a known history of [pertinent medical condition] presents with a [duration] history of [chief complaint]. [If they are accompanied by someone then write: Patient is accompanied by [family, friend, caregiver, police, other], [Name if mentioned]. Patient describes [pertinent positives and negatives]. Associated symptoms include [pertinent associated symptoms]. Denies [pertinent negatives].

Past Medical/Surgical History Pertinent to Presentation

[This should be very brief - this is for our minor patient track] [Relevant medical and surgical history related to the chief complaint and major illnesses, Please list these separated by a comma]

Social History

[This should be very brief - this is for our minor patient track] [ER_mode: Only generate content for Social History sections that are explicitly discussed in the transcript of patient-doctor dialogues or if I mention it based on triage note or chart review 1. Omit any system that is not mentioned or assessed 2. Do not add any additional systems or information not specified in this template 3. Do not include a system unless it was discussed. Each assessment must start on a new line] - Tobacco: [Current smoker, Former smoker, Never smoked] - Alcohol: [alcohol use] - Drug Use: [drug use] - Housing: [If discussed, living on the street, living rough, staying in a shelter, couch surfing, housed] - Occupation: [occupation] - Living Situation: [living situation]

Current Medications

[This should be very brief - this is for our minor patient track] [medication 1] [dosage 1 if mentioned] [medication 2] [dosage 2 if mentioned] [Do not add a medication if it is not part of the transcript and do not write Presumed

Physical Examination

[This should be very brief - this is for our minor patient track] [ER_mode: Only generate content for ROS, vitals & PE sections that are explicitly discussed in the transcript of patient-doctor dialogues 1. Omit any system that is not mentioned or assessed 2. Do not add any additional systems or information not specified in this template 3. Each system assessment must start on a new line] General: eg: [Patient appears in no acute distress or if mentioned Patient is unkempt, note any obvious injury, whether they are alert and oriented x 3] HEENT: eg: [HEENT findings] Cardiovascular: eg: [Cardiovascular findings,] [If I say normal heart - write : CV = S1, S2, no murmurs] Respiratory: eg: [Respiratory findings], [If I say normal resp- write : Lungs: A/E = B/L, no crackles, no wheese] Gastrointestinal: eg: [Gastrointestinal findings] Genitourinary: eg: [Genitourinary findings] Musculoskeletal: eg: [Musculoskeletal findings] Neurological: eg: [Neurological findings] Skin: eg: [Integumentary findings]

Test Results

[This should be very brief - this is for our minor patient track] Do not summarize the labs - it is important to include the results if I provide them. - Lab: [Lab results, bloodwork, sputum,urinalysis. Put each lab test type on a new line i.e. Na 128, Trop #1 11, Repeat Troponin 16, If I state CBC normal, write CBC is within normal limits, and similar for other bloodwork mentioned - Imaging: [Imaging results] - EKG: [EKG results]

Impression and Management Plan

[This should be very brief - this is for our minor patient track] [At the end of my initial assessment, I will discuss with the patient my differential diagnosis and next steps (e.g. pending tests, additional investigations that I will order and treatment plans) Please write this in concise format starting with impression and then next steps) IMPRESSION: ( My differential diagnosis or presumed diagnosis as well as why I have ruled out other causes, use bullet points to list these for each potential diagnosis) NEXT STEPS: ( pending tests, additional investigations that I will order and treatment plans, use bullet points to list these)

Reassessment Note

Time of Reassessment (based on supplementary note) Symptom Changes and Response to Interventions: [Record any changes in pain level, mobility, neurological symptoms, as well as any new symptoms that have developed or previous symptoms that have resolved since the initial assessment. Document the patient's response to treatments, medications, IV fluids, etc.] Physical Exam: [only list if there are changes in pertinent findings] New Test Results: [only list if these are mentioned results of labs, imaging, etc.] Updated Plan: [This should be very brief - this is for our minor patient track] - Further tests: [New and pending labs, imaging, and other tests] - Further treatment: [Treatment, e.g. IV fluids] - Disposition: [Consult for to hospital, discharge home, transfer to higher level of care, etc.] - Follow up: [Follow up instructions, e.g. follow up to be arranged with family physician]

Reassessment Note

Time of Reassessment (based on supplementary note) Symptom Changes and Response to Interventions: [Record any changes in pain level, mobility, neurological symptoms, as well as any new symptoms that have developed or previous symptoms that have resolved since the initial assessment. Document the patient's response to treatments, medications, IV fluids, etc.] Physical Exam: [only list if there are changes in pertinent findings] New Test Results: [only list if these are mentioned results of labs, imaging, etc.] Updated Plan: [This should be very brief - this is for our minor patient track] - Further tests: [New and pending labs, imaging, and other tests] - Further treatment: [Treatment, e.g. IV fluids] - Disposition: [Consult for to hospital, discharge home, transfer to higher level of care, etc.] - Follow up: [Follow up instructions, e.g. follow up to be arranged with family physician]

Handover to next MD

[Only list if I mention this] [If relevant in my notes or supplementary notes, at the end of my shift please state: At XX:XX, I provided handover to Dr. to follow-up on the care that we started.

Disposition

[Please bullet each sentence, This should be very brief - this is for our minor patient track] [If relevant , write This patient has been referred to... [e.g. medicine, ophtho, GI, TACS/General Surgery, etc.] for consideration of admission. [If being discharged write: The patient should follow up with their family doctor [name the doctor if it is mentioned] and their regular specialist [name the kind of specialist e.g. cardiologist, nephrologist, general surgeon, etc. plus their specialists name if it is named] We have referred you to a ...[note the kind of specialist that they are being referred to and if the appointment has been made, please add that information in. e.g. we have referred you to the fracture clinic and the appointment is on Tuesday April 23, 2026 at 09:00] [If relevant:] You should return on [date e.g. tomorrow, day after tomorrow (use the date)] for a [describe the imaging test or other intervention] This patient should return to the ED should their symptoms get worse or have any concerns