KC ER General Note

Chief Complaint

[ER General Note]

History of Present Illness

{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]. The patient describes [pertinent positives and negatives]. Associated symptoms mentioned include [pertinent associated symptoms].

Past Medical History

[List pertinent medical history only if discussed, otherwise remove entire section](list using numerical format with each item on one line)

Social History

[List relevant social history only if explicitly asked or mentioned, otherwise do not include this section in note] - Tobacco: [Current smoker, Former smoker, Never smoked] - Alcohol: [alcohol use] - Drug Use: [drug use] - Occupation: [occupation] - Living Situation: [living situation]

Past Surgical History

Relevant Medications Discussed:

[medication 1] [dosage 1] [medication 2] [dosage 2]

Physical Examination

[Always start this section with "Vitals: See nursing assessment in EMR. Well, non-toxic, no acute respiratory distress." unless I explicitly mention that the patient does not appear well, appears septic or toxic, or is demonstrating respiratory distress.] [Only include systems if they were explicitly mentioned. Do not add any systems that were not included] CV/Resp: eg: [Cardiovascular and/or Respiratory findings] HEENT: eg: [HEENT findings] Abdo: eg: [Gastrointestinal findings] GU: eg: [Genitourinary findings] DRE [If this is a female patient, include "with chaperone"]: eg: [Rectal exam findings] PELVIC with chaperone: eg: [Pelvic exam findings] MSK: eg: [Musculoskeletal findings] NEURO: eg: [Neurological findings] DERM: eg: [Integumentary findings] TOX: eg: [Toxicological findings] TRAUMA: eg: [Trauma findings] POCUS: eg: [point of care ultrasound findings] [If this is in the context of a trauma activation then override this entire section with the text below.] PRIMARY SURVEY A: C-spine collared. Airway patent, protected, clear, midline. B: Clear EAE bil. C: CAPL nil acute. D: GCS 15. PERL 3 bil. Limbs x 4. E: Logroll nil acute. eFAST negative. SECONDARY SURVEY [Secondary survey findings such as detailed musculoskeletal and neurological findings]

Investigations:

[Only list if I explicitly mentioned that investigations were done or are going to be done; otherwise exclude entire section] - Labs: [Lab results] - ECG: [ECG results] - Imaging: [Imaging results]

Procedures:

[Generate a concise procedure note for procedures performed. Only include this section if explicitly mentioned, otherwise exclude entire section. Always start with "Informed consent obtained." ]

Course in ED:

[Generate a concise summary of actions, treatments, medications, IV Fluids, etc. that took place over the course of this patient's ED visit in point form, e.g., "Analgesia/antiemetics PRN", "Ceftriaxone IV started", "IV fluids", etc.]

Impression and Plan

This patient presents with [chief complaint]. The most responsible diagnosis is believed to be [working diagnosis]. I do not think the patient has [list 3-4 top differential diagnoses](list the differential diagnoses on one line, with a comma as the delimiter) or other dangerous pathology. [Describe the management plan] [Describe the discharge plan and any follow up arranged]

Patient Discharge Instructions

[Generate patient discharge instructions based on my Impression and Plan section using grade 8 language. Always include instructions on following up with family physician or walk-in clinic or Urgent Primary Care Centre (UPCC). Always include Return to Emergency Department instructions, even if not explicitly mentioned, and at least include “Return to emergency if symptoms worsens.”]

Reassessment Note

[Only include this section if I explicitly mentioned that I am reassessing the patient] Time Interval: [interval, e.g., “1 hour after initial assessment”] 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.] Vital Signs: Temp [temp], HR [HR], BP [BP], RR [RR], SpO2 [SpO2] Physical Exam: [changes in pertinent findings] New Test Results: [results of labs, imaging, etc.] Updated Plan: - Further tests: [New and pending labs, imaging, and other tests] - Further treatment: [Treatment, e.g. IV fluids] - Disposition: [Admit 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

[Only include this section if I explicitly mentioned that I am reassessing the patient] Time Interval: [interval, e.g., “1 hour after initial assessment”] 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.] Vital Signs: Temp [temp], HR [HR], BP [BP], RR [RR], SpO2 [SpO2] Physical Exam: [changes in pertinent findings] New Test Results: [results of labs, imaging, etc.] Updated Plan: - Further tests: [New and pending labs, imaging, and other tests] - Further treatment: [Treatment, e.g. IV fluids] - Disposition: [Admit 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]