EMERGENCY 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]