An emergency department note is the emergency physician’s record of one ED visit: triage, a focused history and exam, the ED course with times, the results, your reasoning and decision rules, and the disposition. Copy the free ER note template, see a chest pain sent home after two troponins and an older adult with a head strike on a blood thinner, and check what goes in each part.
Blank emergency department note template
FreeEMERGENCY DEPARTMENT NOTE Patient: [Name, age, sex] Date of birth: [Date] Record number: [Chart or record number] Date of visit: [Date] Arrival: [Time, and how the patient came: walk-in, ambulance, police, or transfer from another site] Seen by physician: [Time first seen] Source of history: [Patient, family, paramedics, or records; interpreter if used] Primary care clinician: [Name, or none] Emergency physician: [Name, credentials] TRIAGE Triage level: [Level and scale, such as ESI or CTAS, and what the triage nurse flagged] Triage vital signs: [BP, HR, RR, temperature, SpO2, pain score, and glucose if taken, with the time] Chief complaint: [The reason for the visit in the patient's words, and how long ago it started] HISTORY History of present illness: [Onset, timing, character, severity, associated symptoms, what was tried, and why the patient came in now] Pertinent positives and negatives: [The findings that bear on the dangerous causes of this complaint] Relevant history: [Past medical and surgical history, recent visits or procedures, and pregnancy status when relevant] Medications: [Current medications, with any anticoagulant or antiplatelet and the time of the last dose] Allergies: [Drug and other allergies, with the reaction] Social history: [Tobacco, alcohol, drugs, who the patient lives with, and who can help at home] EXAMINATION General: [Appearance, distress, mental status, and GCS when relevant] Focused exam: [Findings by system for this complaint, including the negatives that matter] ED COURSE [Time]: [Test ordered, medication given with dose and route, procedure, reassessment, or call made] Reassessments: [Time, symptoms, repeat vital signs, and response to treatment] Consultations: [Service, consultant's name, time called, time they replied, and their advice] RESULTS Labs: [Each result with the time drawn, abnormal values marked, and repeat values] ECG: [Time, rhythm, rate, intervals, ST and T changes, comparison with an old tracing, and your read] Imaging: [Study, time, who read it, and the findings] Pending: [Results not back at disposition, or none] MEDICAL DECISION MAKING Differential diagnosis: [Diagnoses considered, dangerous ones first, and why each is more or less likely] Decision rules: [Rule by name, each part with its score, the total, and what it means for this patient; or why a rule does not apply] Reasoning: [How the history, exam, results, and ED course lead to the diagnosis and the disposition] Decision complexity: [Problems addressed, data reviewed, and risk of the decisions made, if your billing uses them] ED diagnosis: [Final or working diagnosis, and other problems addressed] DISPOSITION Disposition: [Discharged, admitted, observation, transferred, left before care was finished, or left against medical advice, with the time] Why this disposition: [The findings that make it safe, and what was weighed against it] Condition at disposition: [Symptoms and last vital signs] Medication changes: [New, stopped, or held medicines, with dose and duration] Follow-up: [With whom and when; pending results and who will act on them] Return precautions: [The specific signs that mean come back or call 911, how they were given, and the patient's understanding] HANDOFF Handoff: [Time, from whom to whom, open tasks, and the plan if the patient improves or gets worse; or none] Signed: [Emergency physician name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Emergency department, adult walk-in, discharged home the same afternoon
Arrived 2:05 p.m., walk-in, driven by a coworker. Triage 2:09 p.m.: ESI 2, chest pain with cardiac risk factors; ECG ordered at triage and done at 2:11 p.m., 6 minutes after arrival. Seen by me at 2:20 p.m. Triage vital signs: BP 148/88, HR 82, RR 16, T 36.8 °C (98.2 °F), SpO2 99% on room air, pain 1 out of 10. 52-year-old woman. Chief complaint: “A tight, burning feeling in the middle of my chest after lunch.” Started 75 minutes before arrival.
Central chest tightness began at 12:50 p.m., about 20 minutes after a large lunch, while sitting at her desk. Burning, with a sour taste in her mouth; 5 out of 10 at its worst; no spread to the arms, jaw, or back. No sweating, nausea, breathlessness, palpitations, or fainting. Eased slowly over 45 minutes; a faint ache remained on arrival. Climbed 2 flights of stairs this morning without symptoms. Milder burning after meals 3 or 4 times in the past month. Not worse with breathing or movement; not tearing. No leg swelling, recent surgery, long travel, previous clot, coughing blood, or cancer. History: high blood pressure and high cholesterol; no diabetes or known heart disease. Medications: lisinopril 10 mg daily, rosuvastatin 10 mg daily; no anticoagulant. Allergies: sulfa antibiotics, rash. Never smoked; 2 or 3 drinks a week; no cocaine or other drugs. Mother had a heart attack at 74; no early heart disease in the family. Lives with her husband; works as a school administrator.
Well and comfortable, talking in full sentences. BP 148/88 right arm, 144/86 left arm. Heart regular, normal sounds, no murmur or rub. Lungs clear, air entry equal. Chest wall not tender. Abdomen soft; mild tenderness in the upper middle abdomen, no guarding, no right upper quadrant tenderness. Radial and femoral pulses equal. No leg swelling or calf tenderness. BMI 27.
2:11 p.m.: ECG, read by me at 2:13 p.m. 2:15 p.m.: high-sensitivity troponin, CBC, electrolytes, creatinine, lipase, and D-dimer drawn. 2:22 p.m.: aspirin 325 mg chewed. 2:40 p.m.: chest X-ray; pain gone, with no other treatment. 3:30 p.m.: reassessed, pain-free; BP 136/84, HR 74. 4:15 p.m.: repeat troponin and ECG, 2 hours after the first. 4:50 p.m.: results and plan reviewed with her and her husband. No consultations.
High-sensitivity troponin 4 ng/L at 2:15 p.m. and 5 ng/L at 4:15 p.m.: both below the assay’s 99th percentile, with a change of 1 ng/L. D-dimer 0.32 mg/L FEU. Hemoglobin 13.4 g/dL (134 g/L); electrolytes normal; creatinine 0.8 mg/dL (71 µmol/L); lipase normal. ECG 2:11 p.m.: sinus rhythm at 80, normal axis and intervals, no ST or T-wave changes; the same as her 2023 tracing. ECG 4:15 p.m.: unchanged. Chest X-ray: normal heart size and mediastinum, clear lungs, no pneumothorax; my read, and the radiologist agreed at 3:20 p.m. Nothing pending.
Differential: acute coronary syndrome, pulmonary embolism, aortic dissection, pericarditis, pneumothorax, reflux or esophageal spasm, biliary pain. HEART score 3, low risk. History 1, moderately suspicious: central tightness, but at rest after a meal, with burning and a sour taste. ECG 0: normal and unchanged. Age 1: 45 to 64. Risk factors 1: high blood pressure and high cholesterol, 2 factors. Troponin 0: below the 99th percentile. Two troponins below the cutoff, 2 hours apart, with no rise: myocardial infarction ruled out. Pulmonary embolism: Wells 0, with no leg signs, heart rate under 100, no surgery or immobilization, no previous clot, no coughing blood, no cancer, and another diagnosis more likely. PERC can’t be used at 52, so a D-dimer: 0.32 mg/L FEU, below her age-adjusted cutoff of 0.52, so no CT. Dissection unlikely: no tearing or back pain, arm pressures 4 mmHg apart, equal pulses, normal mediastinum. No rub or ECG changes to suggest pericarditis; no pneumothorax on X-ray. Normal lipase and no right upper quadrant tenderness. ED diagnosis: chest pain, acute coronary syndrome ruled out; most likely reflux.
Discharged home at 4:55 p.m. Why: low-risk HEART score with two troponins below the cutoff and no rise; pulmonary embolism and dissection excluded; pain-free for over 2 hours. Admission and stress testing considered; neither needed at this risk level. Condition: pain-free; BP 134/82, HR 72, SpO2 99%. New: omeprazole 20 mg daily before breakfast for 4 weeks. Continue lisinopril and rosuvastatin. The aspirin was a single dose in the ED, not continued. Follow-up: her family physician within 1 week, to review the reflux, her blood pressure, and whether outpatient heart testing is needed. Return precautions: call 911, and don’t drive herself, for chest pain or pressure lasting more than 5 minutes, pain that comes on with exertion, or pain with sweating, breathlessness, or fainting. Printed copy given; she repeated the signs back.
None: seen and discharged by the same physician.
Emergency department, arrived by ambulance, observed for 6 hours, discharged home with family
Arrived 11:25 a.m. by ambulance, with his wife. Triage 11:28 a.m.: CTAS 2, flagged for a head strike on an anticoagulant. Seen by me at 11:35 a.m. Triage vital signs: BP 156/84, HR 72 irregular, RR 16, T 36.6 °C (97.9 °F), SpO2 97% on room air, glucose 115 mg/dL (6.4 mmol/L), pain 3 out of 10, GCS 15. 74-year-old man. Chief complaint: “I tripped on the hose and hit my head on the patio.” 45 minutes before arrival.
Tripped on a garden hose at 10:40 a.m. while watering, fell forward, and hit the right side of his forehead on the patio. His wife saw it: no loss of consciousness; he got up by himself within a minute, talking normally. Remembers the whole event. Mild headache at the front since. No vomiting, change in vision, confusion, weakness, numbness, trouble speaking, seizure, or neck pain. No dizziness, chest pain, or palpitations before the fall. No other falls this year. History: atrial fibrillation for 4 years, high blood pressure, enlarged prostate. Medications: rivaroxaban 20 mg with dinner, last dose at 6:30 p.m. yesterday; metoprolol 50 mg twice daily; tamsulosin 0.4 mg at bedtime. No known drug allergies. Tetanus booster 3 years ago. Lives with his wife in a one-level house; independent, walks daily. 1 beer most days, none today; never smoked. Weight 80 kg (176 lb).
Alert and oriented, GCS 15: eyes 4, verbal 5, motor 6. 2.5 cm laceration over the right forehead with swelling around it; clean edges, no debris, bone not felt. No other scalp swelling; no bruising behind the ears or around the eyes; no blood or clear fluid from the nose or ears. Pupils 3 mm, equal and reactive; eye movements full. Facial bones not tender. Speech normal; strength 5 out of 5 and sensation normal in all limbs; finger-to-nose normal. No midline neck tenderness; range of motion not tested before imaging. Heart irregularly irregular, no murmur; chest clear. Grazes on both palms; wrists, hips, and pelvis not tender.
11:40 a.m.: CT head and cervical spine without contrast ordered; CBC, electrolytes, creatinine, and ECG. 11:46 a.m.: ECG, read by me. 12:05 p.m.: CT done. 12:40 p.m.: radiologist’s report reviewed. 12:50 p.m.: bleeding stopped with pressure; laceration irrigated with saline and closed with tissue adhesive. 1:00 p.m.: acetaminophen 1,000 mg by mouth. Neuro checks every hour from 1:00 p.m.: GCS 15 and pupils equal each time; headache 1 out of 10 by 2:00 p.m. 2:15 p.m.: neck cleared after the normal CT: full, painless movement. BP lying 152/84, HR 70; standing at 3 minutes 146/82, HR 76; no dizziness. Walked the corridor steadily. 3:00 p.m.: handed over to Dr. Aisha Bello.
CT head: no bleeding inside the skull, no skull fracture; soft tissue swelling over the right forehead. CT cervical spine: no fracture or malalignment; degenerative changes at C5 to C6. Both reported by the radiologist at 12:40 p.m. ECG 11:46 a.m.: atrial fibrillation at 74, no acute ST changes. Hemoglobin 14.1 g/dL (141 g/L); platelets normal; electrolytes normal; creatinine 1.0 mg/dL (88 µmol/L). Creatinine clearance about 73 mL/min by Cockcroft-Gault at 80 kg, so 20 mg daily is the right rivaroxaban dose for him. Rivaroxaban level not measured: no reversal needed with a normal CT. Nothing pending.
Differential: bleeding inside the skull, skull or cervical spine fracture, a faint or heart rhythm problem as the cause of the fall, and other injuries. The CT head rule doesn’t apply: patients on anticoagulants were excluded when it was derived. CT head done because of the anticoagulant and his age. Neck scanned at the same time: the cervical spine rule counts age 65 or over as high risk. Both scans normal. Cause of the fall: a trip, seen by his wife, with no warning symptoms. ECG shows his known atrial fibrillation with a controlled rate; no drop in blood pressure on standing; glucose normal. Not a faint. A delayed bleed after a normal first CT is uncommon; no repeat scan unless his symptoms change. Plan: neuro checks until 6 hours after the fall, then home with an adult staying the night. Rivaroxaban continued: CHA2DS2-VASc 2, for high blood pressure 1 and age 65 to 74 1, with no heart failure, diabetes, stroke, or vascular disease; his stroke risk outweighs the bleeding risk after a normal scan. ED diagnosis: head injury without bleeding inside the skull, on an anticoagulant; forehead laceration; mechanical fall.
Addendum by Dr. Aisha Bello at 4:50 p.m.: neuro checks normal through 4:40 p.m., 6 hours after the fall; no headache; walking steadily. His daughter arrived and will stay the night. Discharged home at 4:45 p.m. Why: GCS 15 throughout, normal CT head and neck, a mechanical fall with no sign of a faint, and an adult with him tonight. Overnight admission for observation considered; not needed. Condition: GCS 15, BP 144/80, HR 70. Medicines: rivaroxaban continued, next dose with dinner tonight; acetaminophen for pain; no ibuprofen or other anti-inflammatories. Wound: don’t scrub or pick the glue; it peels off in 5 to 10 days. Follow-up: family physician in 1 week for a falls review, including the timing of tamsulosin and safety at home. Return precautions: call 911 for a worsening headache, vomiting more than once, confusion or unusual sleepiness, weakness, numbness, trouble speaking or walking, a seizure, or clear fluid from the nose or ears. Head injury sheet given to him and his daughter; she repeated the signs back.
3:00 p.m., face to face at the bedside, Dr. Owen Hart to Dr. Aisha Bello, incoming emergency physician. 74-year-old on rivaroxaban, mechanical fall with a head strike at 10:40 a.m.; CT head and neck normal; laceration closed; neuro checks normal so far. To do: neuro checks every hour until 4:40 p.m.; home if GCS 15, walking steadily, and his daughter is there. If his GCS falls, his headache worsens, or he vomits: repeat CT head at once, and if it shows a bleed, give reversal and call neurosurgery.
When and how the patient arrived, the triage level, and the first vital signs. The times show how quickly a sick patient reached a physician.
Avoid: Leaving out the arrival, ECG, and first-seen times. For chest pain, stroke, and sepsis, those intervals are the first thing a chart review checks.
A focused history built around the dangerous causes of this complaint, with the details that change the workup.
Avoid: A review of systems with every box ticked negative. Write the negatives that rule a dangerous cause in or out, such as tearing pain or loss of consciousness.
The exam that answers today’s question, with the negatives that matter.
Avoid: “Neuro intact.” Write what you tested: GCS, pupils, strength, sensation, speech, and gait.
The timeline of the visit: each test, treatment, reassessment, and call, with its time. It shows how the patient changed while in your care.
Avoid: A course with no times. “Troponin negative x2” doesn’t show the interval, and the interval is what makes the result mean something.
Every result that shaped the decision, with its time, your read, and who else read it.
Avoid: A troponin with no time or cutoff. Give the value, the time drawn, and how it compares with your assay’s 99th percentile.
Your reasoning: the differential, the decision rules you used, and how the findings lead to the diagnosis and the disposition.
Avoid: A score with no parts. “HEART 3” can’t be checked; “history 1, ECG 0, age 1, risk factors 1, troponin 0” can.
Where the patient went, why that was safe, and what they need to know if things change.
Avoid: “Stable for discharge.” Name the findings that make home safe, and the warning signs that should bring the patient back.
When care passes to another physician at shift change: what was handed over, and what is still to do.
Avoid: A handoff that is only a to-do list. Say what should happen if the next check is abnormal, so the incoming physician doesn’t start over.
Write each part of the HEART score, Wells, or PECARN with its points, then the total. A bare number can’t be checked by the next physician or a reviewer.
PERC only rules out a clot below age 50. The CT head rule wasn’t made for patients on anticoagulants, and PECARN is for children. Say when a rule doesn’t apply, and what you did instead.
Serial troponins, observation periods, and the gap between a dose and a reassessment all depend on the clock. Put a time on every test, treatment, and recheck.
“Stable for discharge” says nothing about why home is safe. Write the findings that support it, what you considered instead, and who the patient goes home with when that matters.
A culture, a radiologist’s final read, or a level still running at discharge needs an owner. Write who will check it and how the patient will hear.
Vero Scribe writes the emergency department note in your template from the visit, with the patient’s consent, or from your dictation. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
Arrival and triage, a focused history and exam, the ED course with times, the results with your read, your medical decision making with any decision rules, the ED diagnosis, the disposition and why it is safe, return precautions, and a handoff if care changed hands. An ER note and an ED note are the same document.
An urgent care note covers one walk-in visit and the tests done on site, and often ends in a transfer to the ED. The ED note adds what a longer stay needs: serial tests, reassessments and consults with times, observation, and handoffs. When the ED admits the patient, the inpatient team writes an admission H&P, with medication reconciliation, code status, and level of care.
In time order, one line per event: tests ordered, medicines with dose and route, reassessments with repeat vital signs, results as they come back, and calls to consultants with the time they replied. The times show the intervals that matter, such as two troponins 2 hours apart, or 6 hours of neuro checks after a head injury.
Common ones are the HEART score for chest pain, Wells and PERC for a suspected clot in the lungs, the CT head rule after a minor head injury in adults, and PECARN for head injury in children. Write each part and the total, and say when a rule doesn’t apply: PERC only below age 50, and the CT head rule not for patients on anticoagulants.
Yes. Copy it, or download it as a Word or text file. No account needed.
The trauma team’s record: MIST handover, primary survey, eFAST, blood and tranexamic acid, secondary survey, AMPLE, and times.
ED notes drafted from the visit, for your review.
Common codes for the ED diagnoses in your note.
How scribes fit an ED shift, and how to check reassessments and handoffs in their notes.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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