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.]

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. For example, chronic obstructive pulmonary disease should be COPD. Include past surgical history in this section ]

Medications

[Detailed list of current medications and dosages, ensuring they are extracted from the HPI and listed separately.]

Family History

[Include significant medical conditions in first-degree relatives, e.g., diabetes, hypertension, heart disease, genetic disorders. Do NOT include this heading UNLESS IT IS DISCUSSED in the transcript.]

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.]

Vital Signs

[Include blood pressure, heart rate, respiratory rate, temperature, weight, height, BMI, head circumference if applicable. If nothing said, put "As per electronic triage."]

Physical Examination

General: [Standard findings or specific details if abnormalities are noted. If not stated, put NAD, GCS 15.] ENT: [Document findings like PERRL 3mm, normal oropharynx, etc., as stated.] Chest: [Details such as GAEB, any abnormal breath sounds, etc. If stated as normal, put GAEB, no increased WOB, no crackles or wheezes.] CVS: [Standard cardiac exam findings: S1 S2, no S3 S4, no murmur. PPP x 4 extremities. No leg swelling or tenderness or specific details if abnormalities are noted.] Abd: [Details on abdominal exam, e.g., soft, non-tender, no rebound or guarding, no CVAT.] Neuro: [Neurological findings such as CN III-XII normal, Strength 5/5 x 4 extremities, normal sensation to light touch, no PD, normal FNF, normal gait, etc or specific details if abnormalities are noted.] MSK: [Comprehensive musculoskeletal exam findings, specify details on ROM, strength 5/5 x 4 extremities, tenderness, deformities, and specific injuries or abrasions, including the location and description.] Skin: [Details on skin examination, noting any rashes, lesions, or other concerns.] ECG: [Detail the stated results of the ECG] POCUS: [Detail the stated results of bedside ultrasound findings as described]

Clinical Impression and Differential Diagnosis

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

Plan

Treatments: [Include medications prescribed or given including fluids with doses if 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.]

Investigations

Labs: [Specific labs ordered with details, using Canadian SI units.] Imaging: [Details of imaging studies ordered.] ECG: [Details of ECG findings if performed.]

Reassessment Note

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

Disposition

[Always include this heading, even if not mentioned. If mentioned include a heading for 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.]