NEW ER General Note

Chief Complaint

[Document the patient's primary reason for visiting the emergency room, including any relevant details about the complaint's onset, duration, and severity.]

History of Present Illness

[age] years old [gender] with a known history of [pertinent medical condition] presents with a [duration] history of [chief complaint]. Patient describes [pertinent positives and negatives]. Associated symptoms include [pertinent associated symptoms]. Denies [pertinent negatives].

Past Medical History

Past Surgical History

Family History

[Relevant family history related to the chief complaint and major illnesses]

Social History

- Tobacco: [Current smoker, Former smoker, Never smoked] - Alcohol: [alcohol use] - Drug Use: [drug use] - Occupation: [occupation] - Living Situation: [living situation]

The Review of Systems

- General: eg: Fatigue, weight changes, appetite changes, behavioral changes such as irritability or mood swings, general malaise - Head: eg: Headache - Eyes: eg: Vision changes - Ears: eg: Hearing loss - Throat: eg: Sore throat - Nose: eg: Nasal congestion - Cardiovascular: eg: Chest pain, palpitations, orthopnea, edema - Respiratory: eg: Shortness of breath, cough, wheezing - Gastrointestinal: eg: Nausea, vomiting, diarrhea, constipation, abdominal pain - Genitourinary: eg: Dysuria, frequency, urgency, hematuria - Musculoskeletal: eg: Joint pain, swelling, stiffness, muscle weakness - Neurological: eg: Dizziness, weakness, numbness or tingling, headache - Integumentary: eg: Rash, itching, bruising, wounds - Psychiatric: eg: Anxiety, depression, suicidal ideation - Hematologic: eg: Easy bruising, bleeding - Lymphatic: eg: Lymphadenopathy - Endocrine: eg: Polyuria, polydipsia, heat or cold intolerance - Allergy and Immunology: eg: Seasonal allergies, recurrent infections STRICT_MODE: 1. Only generate content for systems that are explicitly discussed in the transcript of patient-doctor dialogues 2. Omit any system that is not mentioned or assessed 3. Do not add any additional systems or information not specified in this template 4. Each system assessment must start on a new line.

Current Medications

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

Vital Signs

Temp [temp], HR [HR], BP [BP], RR [RR], SpO2 [SpO2] STRICT_MODE: 1. Omit any parameter that is not mentioned or assessed. 2. Only include the parameters that have been mentioned or assessed.

Physical Examination

General: eg: Patient appears in no acute distress HEENT: eg: [HEENT findings] Cardiovascular: eg: [Cardiovascular findings] Respiratory: eg: [Respiratory findings] Gastrointestinal: eg: [Gastrointestinal findings] Genitourinary: eg: [Genitourinary findings] Musculoskeletal: eg: [Musculoskeletal findings] Neurological: eg: [Neurological findings] Integumentary: eg: [Integumentary findings] STRICT_MODE: 1. Only generate content for systems that are explicitly discussed in the transcript of patient-doctor dialogues 2. Omit any system that is not mentioned or assessed 3. Do not add any additional systems or information not specified in this template 4. Each system assessment must start on a new line.

Test Results

- Lab: [Lab results] - Imaging: [Imaging results] - EKG: [EKG results]

Assessment and Plan

Assessment and Plan

Reassessment Note

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]

Summary Statement

[Summarize the patient's current status, including key findings from the reassessment. Highlight any critical changes or decisions made regarding the patient's care plan. Include any recommendations for further treatment or follow-up.]