ER Fraser Health SOAP note

Asessment Time

[XXXXh format only. Use dictated time. If none dictated, use recording start time minus 5 minutes.]

Referring MD

[Insert referring clinician's name if provided. Omit if none. Never list Dr. Alexander Suleiman.]

Reason for referral

[Brief statement of why the patient was sent by the referring clinician.]

Chief Complaint

Emergency Department SOAP Note Template -- [Chief Complaint: e.g., Cephalgia x3 days]

History of present illness

[If referral: State when seen by referrer and reason for ER transition.] [Bullet points for onset, duration, symptoms, triggers.] [Include "Impressions" of any imaging reports provided.] Review of Systems (ROS): [Brief list of negatives: e.g., No fever, no URTI, no CP, no urinary symptoms.]

Past medical history

[Condition 1] [Condition n]

Medication (including allergies)

[Medication List - Check context for electrolyte-correcting drugs.] [Allergies - If none, state "NKDA".] See MAR for complete list

Physical examinations: General

[Appearance, ambulation, skin color.] [If normal exam is dictated, insert the following:] CARDIAC: NS1S2, no EHS, pulses symmetric at radials BIL. RESPIRATORY: Normal WOB, SFS, GAEB, no adventitious sounds. ABDOMEN: SNT, no HSP, no peritonism.

Heart

[Pulse regularity, heart sounds, murmurs, JVP if mentioned.]

Respiratory

[Work of breathing, breath sounds, adventitious sounds.]

Abdomen

[Inspection, bowel sounds, palpation, Murphy/McBurney signs, hernia.]

Investigations (including orders/results)

[Labs: e.g., CBC WNL, CRP (Value).] [Imaging: Include "Impressions" and main takeaway.]

ER treatment

[Diagnosis/Findings discussed with patient.] [Treatment options and interventions.] [Test results summary.] [Recommendations and follow-up.] [Discharge/Admission criteria and return-to-ER precautions.]

Primary ER diagnosis

[Identifying statement: e.g., "72yo female with PMH of HTN and AFib presenting with acute onset aphasia and right-sided weakness concerning for acute ischemic stroke."] [Diagnosis 1] [ICD-9 Code] [Clinical reasoning/Differential logic.] [Diagnosis 2] [ICD-9 Code]

Disposition and management plan

[Disposition: e.g., Home, Ward, ICU.] [Follow-up timeframe.] [Reasoning for decisions (e.g., "IV antibiotics initiated due to systemic febrile response").]

Medications & management

[Name, Dose, Frequency, Route, Duration] [Example: Ceftriaxone 1g IV daily x1]

Reassessment

[Required only if mentioned. Time logic: Dictated time OR Initial Assessment + 2h 1m.] [Reason for reassessment, response to therapy, changes in clinical status, final disposition support.]

Resuscitation

[Required only if "Resuscitation" or "Critical Care" is explicitly stated.] [Start Time]-[End Time] Indication: [e.g., Unstable bradycardia] A: [Airway status] B: [Breathing/Ventilation] C: [Circulation/Access] D: [Disability/AVPU] E: [Exposure/Trauma] Intervention: [e.g., Synchronized cardioversion 200J]

Procedure

[List names of procedures only. No colloquialisms.]

Specialist consultation

"Dr. [Name/Service] was consulted at [XXXXh] to review the case and obtain urgent management advice." [Management plan as advised by consultant.] [Interventions, safety risks, follow-up.] "The management plan was discussed with the patient/representative." [Specify if seen in ER or advice only.]