New Level 2/3 Emerg Note

Chief Complaint

New Level 2/3 Emerg Note

History of Present Illness

[Be extremely detailed. Clearly document all symptoms, relevant history, and details about current medical symptoms. Be specific about their duration, nature, severity, exacerbating and alleviating factors. You must document this section in paragraph form.] [Never include physical exam findings in the HPI. Do not include past medical history information in the HPI. If the patient has multiple medical co-morbidities, you may describe the patient as being a "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. Use a bullet point format.]

Past Medical History

[Include all significant medical conditions with dates if available, hospitalizations, major illnesses, surgeries, and any chronic conditions, clearly separated from HPI. Use a bullet point list. Use medical terminology with appropriate abbreviations. Include past surgical history in this section.] Example: • essential tremor • No history of hypertension • No history of diabetes mellitus • No history of hypercholesterolemia

Medications

[Detailed list of current medications and dosages, ensuring they are extracted from the HPI and listed separately.] • [Medication 1] [Dosage & Frequency if mentioned] • [Medication 2] [Dosage & Frequency if mentioned] ...

Family History

[Never include this if it is not mentioned. If mentioned. Include significant medical conditions in first-degree relatives, e.g., diabetes, hypertension, heart disease, genetic disorders. Do NOT include if not mentioned. Do NOT include any subheadings that are not mentioned. You are making more work for me.]

Social History

[Detailed information on the patient’s lifestyle including substance use, occupation, living situation, mobility, activities of daily living, hand dominance, and any relevant social factors.]

MOST

[If mentioned, document the patient’s code status (e.g., C2, C1, C0, M3, M2, M1) and any discussion about code status. Do NOT include any subheadings that are not mentioned. You are making more work for me.]

Vital Signs

[Include blood pressure, heart rate, respiratory rate, temperature, glucose. If nothing said, put "As per electronic triage."]

Physical Examination

[Provide a detailed narrative of the physical examination findings. Include the following sections only when mentioned: General, ENT, Chest, CVS, Abdomen, Neuro, MSK, and ECG and any other examination mentioned. For each section, describe the observations and any notable findings in details and use medical terminology. Use bullet point style for each exam to maintain consistency and clarity] Example: General: She is alert and oriented. Glasgow Coma Scale is 15. ENT: PERRL 3mm. Normal oropharynx. Neck supple. No cervical lymphadenopathy Chest: GAEB, no increased WOB, no crackles or wheezes. CVS: N S1, S2. No S3, S4. No murmurs. PPP present and palpable x4 extremities. No leg swelling or tenderness. Abd: Soft with mild tenderness in the mid-abdomen. No rebound or guarding. No CVAT Neuro: Cranial nerves III through XII are intact. Strength is 5/5 in all four extremities. Sensation to light touch is normal. No pronator drift. FNF normal. Normal gait MSK: No abnormalities noted. Range of motion and strength are preserved in all extremities. ECG: She demonstrates normal sinus rhythm without significant changes compared to previous tracings.

Clinical Impression and Differential Diagnosis

[Detailed differential diagnoses, prioritizing emergent conditions in bullet form. Include ICD 9 code for each. Separate paragragh detailing the overall impressions about the condition of the patient and the working diagnosis as described]

Plan

Treatments: [Include medications prescribed or given including fluids with doses as specified, non-pharmacological treatments, and other interventions. If medications are given, indicate the doses, and use appropriate abbreviations such as p.r.n. for if needed. Include details of all laboratory and imaging tests ordered and consultations planned.]

Plan

Treatments: [Include medications prescribed or given including fluids with doses as specified, non-pharmacological treatments, and other interventions. If medications are given, indicate the doses, and use appropriate abbreviations such as p.r.n. for if needed. Include details of all laboratory and imaging tests ordered and consultations planned.]

Investigations

Imaging: [Detail of imaging if mentioned, include detail findings, type of imaging, and date.] ECG: [Detail of ECG if mentioned, include detailed findings, and date.]

Reassessment Note

[Reassessment plans. (in bullet point). Alway include this heading, even if not mentioned.]

Disposition

[[If mentioned, generate patient Education and follow up as instructed below, otherwise state N/A] 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]]

Consent

This note was created with the assistance of an 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.]