Level 1 Emerg Note

Chief Complaint

Level 1 Emerg Note

History of Present Illness

[Provide a detailed yet concise account of all symptoms, relevant history, and details about current medical symptoms. Include onset, duration, location, severity (scale 1-10), and description of symptoms. Document any previous and ongoing treatments related to the current condition.] [Never include physical exam findings, or past medical history information in the HPI. If the patient has multiple medical co-morbidities, you may describe the patient as having "complex medical patient"]

The Review of Systems

[Document a system-by-system review of symptoms the patient is experiencing, Include all pertinent positives and negatives. Do NOT repeat symptoms that are described in the History of Present Illness. Do NOT include physical exam findings. Do NOT create symptoms that were not discussed.]

Current Medications

[List the patient’s current medications including dosages and any herbal medications or supplements.]

Past Medical History

[Include all significant medical conditions with dates if available, hospitalizations, major illnesses, surgeries, and any chronic conditions, clearly separated from HPI.]

Social History

[Detailed information on the patient’s lifestyle including substance use, occupation, living situation, and any relevant social factors.]

Vital Signs

[Include blood pressure, heart rate, respiratory rate, temperature, weight, height, BMI, head circumference if applicable. If nothing is mentioned state "as per electronic triage note.]

Physical Examination

General: [Include general findings or specify if normal.] Musculoskeletal: [Detailed observations of spinal alignment, ROM, posture, movement strength, flexibility.] Range of Motion (ROM): [Document ROM for affected joints, using degrees.] Muscle Testing: [Results of muscle strength testing, graded on a scale of 0 to 5.] Special Tests: [Include results of any special tests performed.] Functional Assessments: [Describe ability to perform functional tasks.] Palpation Findings: [Notable findings from palpation of affected areas.] ENT/Chest/CVS/Abd/GU/Skin: [Document if mentioned during the encounter.]

Differential Diagnosis

[Detailed differential diagnoses if mentioned, prioritizing emergent conditions.]

Investigations

[List all planned laboratory tests, imaging studies, and other diagnostic tests, specifying which have been ordered during the visit.]

Plan

Orders and Referrals: [Include laboratory tests, imaging studies, referrals to specialists if needed] Treatments: [Include medications prescribed, non-pharmacological treatments, and other interventions] Patient Education: [Discuss educational points provided to the patient’s caregivers, such as lifestyle modifications, disease-specific information] Follow Up: [Include follow-up appointments, monitoring plans]

Plan

Orders and Referrals: [Include laboratory tests, imaging studies, referrals to specialists if needed] Treatments: [Include medications prescribed, non-pharmacological treatments, and other interventions] Patient Education: [Discuss educational points provided to the patient’s caregivers, such as lifestyle modifications, disease-specific information] Follow Up: [Include follow-up appointments, monitoring plans]

Test Results

[Include details of any relevant laboratory tests, imaging studies, or other diagnostic results available at the time of the note.]

Consent

This note was created with the assistance of a PIPEDA compliant AI scribe after verbal consent from the patient or their proxy. All notes are reviewed and edited for accuracy and completeness prior to being signed in the EMR.

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