Specialty: Emergency Medicine Specialist

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Template Structure

Chief Complaint

Summarize the primary reason for the emergency department visit in one concise sentence, including the duration of symptoms.

Past Medical History

[List relevant past medical conditions, if available.]

[Document social history, including lifestyle factors such as occupation or living situation, if available.]

[Note family medical history, if relevant and available.]

[Record smoking, alcohol consumption, and drug use habits, if available.]

Medications

List current medications, including dosage and frequency, noting the source (e.g., electronic record or Connecting Ontario), if available.

Allergies

Document any allergies and their associated reactions, if available.

History of Present Illness

[Provide a detailed narrative of the current symptoms, including onset, duration, severity, aggravating/alleviating factors, risk factors, and exposures.]

[Describe any prior occurrences of similar symptoms, including recent emergency visits, assessments, or hospital admissions within the past year, if available.]

[Note related visits, investigations, management, and diagnoses, if available.]

[Include medications taken for the current issue and the patient’s response, if applicable.]

[List associated symptoms and other relevant history, if available.]

Review of Systems

Constitutional: Note weight changes, fever, chills, night sweats, fatigue, or malaise, if mentioned.

Eyes: Record eye pain, swelling, redness, foreign body sensation, discharge, or vision changes, if mentioned.

Ears, Nose, Mouth, Throat: Document hearing changes, ear pain, nasal congestion, sinus pain, hoarseness, sore throat, rhinorrhea, or swallowing difficulty, if mentioned.

Cardiovascular: Note chest pain, shortness of breath, paroxysmal nocturnal dyspnea, dyspnea on exertion, orthopnea, claudication, edema, or palpitations, if mentioned.

Respiratory: Record cough, sputum production, wheezing, smoke exposure, or dyspnea, if mentioned.

Gastrointestinal: Document nausea, vomiting, diarrhea, constipation, abdominal pain, heartburn, dysphagia, hematochezia, melena, or jaundice, if mentioned.

Genitourinary: Note dysuria, urinary frequency, hematuria, urinary incontinence, flank pain, or changes in urinary flow, if mentioned.

Musculoskeletal: Record arthralgias, myalgias, joint swelling, back pain, or neck pain, if mentioned.

Integumentary: Note skin lesions, pruritus, hair changes, or nipple discharge, if mentioned.

Neurological: Document weakness, numbness, paresthesias, syncope, dizziness, or headache, if mentioned.

Psychiatric: Record anxiety, depression, insomnia, delusions, suicidal ideation, or hallucinations, if mentioned.

Endocrine: Note polyuria, polydipsia, or temperature intolerance, if mentioned.

Hematologic/Lymphatic: Document bruising, bleeding, transfusion history, or lymphadenopathy, if mentioned.

Allergic/Immunologic: Record allergic reactions or autoimmune disorders, if mentioned.

Include only the systems explicitly mentioned in the patient’s assessment.

Physical Examination

General Appearance: Briefly describe the patient’s overall appearance, if noted.

Vital Signs: Record temperature, blood pressure, heart rate, respiratory rate, glucose levels, oxygen saturation, and other relevant vital signs, if available.

HEENT: Document findings related to head, eyes, ears, nose, and throat, if available.

Respiratory: Note respiratory findings, such as air entry, crackles, or wheezes, if available.

Cardiac: Record cardiovascular findings, such as heart sounds or murmurs, if available.

Abdominal: Document findings from palpation or tenderness, if available.

Skin: Note skin findings, such as rashes, if available.

Other: Include additional physical exam findings, if mentioned.

Investigations

[List results of blood work, if available.]

[Document findings from imaging studies, if available.]

[Note ECG results, if available.]

Assessment & Plan

[State the most likely diagnosis and any differential diagnoses, as determined by the physician.]

[Outline the plan for further assessment, diagnosis, and management in the emergency department and post-discharge.]

[Specify recommended medications, including dosage and administration instructions.]

[Provide general patient care advice, tailored to the condition.]

[List danger signs that would prompt a return to the emergency department.]

[Include follow-up recommendations, such as specialist referrals or primary care visits.]

Follow-Up for Primary Care Physician

List specific elements identified by the physician for follow-up by the patient’s primary care provider, in bullet points, if available.

Final/Working Diagnosis

[Indicate whether the diagnosis is final or working.]

[State the primary diagnosis.]