Specialty: Emergency Medicine Specialist

Master Your ED Assessment Notes

-> Download our Good Practices Checklist for Writing ED Assessment Notes to create precise, compliant, and effective notes by completing the form. Ideal for Emergency Medicine specialists to enhance patient care.

Template Structure

Presenting Complaint (PC):

– [Brief summary of the main issue prompting the ED visit.]

History of Presenting Complaint (HPC):

– [Detailed history relevant to the complaint.]

– [Specific symptoms reported.]

– [Pertinent negatives noted.]

– [General clinical condition and course.]

Past Medical History (PMH):

– [Significant medical history relevant to the case.]

– [Current medications being taken.]

– [Documented allergies.]

On Examination (O/E):

– [Vital signs at presentation.]

– [Key physical examination findings.]

Investigations:

– [Diagnostic tests ordered and notable results.]

Clinical Impression:

– [Summary of provisional diagnosis or clinical judgment.]

– [Any red flags or urgent concerns.]

– [Additional tests or evaluations needed.]

Outcome:

– [Summary of discussion with patient and/or family.]

– [Patient education provided.]

– [Planned follow-up or referrals.]

– [Instructions on warning signs and when to return.]

Management Plan:

[Outline of treatment initiated or recommended.]

[Tests or imaging ordered.]

[Follow-up instructions or referrals made.]

[Safety-net advice for the patient.]

Note: Do not create or assume clinical information. Only include details explicitly mentioned in the transcript, contextual notes, or clinical documentation. If a specific section is not referenced, leave it blank.