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Emergency Medicine Physician
20-25 minutes

Emergency Department Documentation

The s10.ai ED note template is expertly crafted for Emergency Medicine Specialists to efficiently document patient interactions in the emergency department. This comprehensive template encompasses sections for the reason for presentation, history of presenting illness, past medical history, medications, allergies, and additional critical details. It also includes management en route with QAS, examination findings, investigations, assessment, and management within the emergency department. By ensuring all vital information is captured accurately, this template aids in precise diagnosis and treatment planning. Perfect for emergency medicine documentation, the s10.ai template streamlines the workflow for clinicians, enhancing efficiency and accuracy in medical record-keeping.

3,331 uses
4.6/5.0
D
Dr. Emily Thompson
Template Structure

Organized sections for comprehensive clinical documentation

REASON FOR VISIT:
- [Reason for visit]
HISTORY OF CURRENT ILLNESS:
- [Onset of symptoms]
- [Description of symptoms]
- [Additional relevant symptoms]
- [Possible triggers or exposures]
- [Relevant background information]
SYSTEMS REVIEW: (If these findings have been mentioned in section above do not repeat here.) (If this section has no content, then delete the whole section.)
- [Relevant findings from system-specific review]
MANAGEMENT DURING TRANSPORT WITH QAS: (If this section has no content, then delete the whole section.)
- [Details of treatment provided by QAS Ambulance enroute to Hospital.]
- [Outcome of treatment provided by QAS Ambulance enroute to Hospital.]
PREVIOUS MEDICAL HISTORY: (Write each new issue on a new line.) (If this section has no content, then delete the whole section.)
- [Relevant medical conditions]
- [Relevant surgical history]
- [Relevant mental health history]
- [Specialist involvement]
CURRENT MEDICATIONS: (If this section has no content, then delete the whole section.)
- [Current medications and dosages]
KNOWN ALLERGIES: (If this section has no content, then delete the whole section.)
- [Known drug allergies]
SOCIAL BACKGROUND: (If this section has no content, then delete the whole section.)
- [Relevant social background]
SUBSTANCE USE HISTORY: (If this section has no content, then delete the whole section.)
- [Relevant alcohol history]
- [Relevant tobacco history]
- [Relevant social drug use history]
FAMILY MEDICAL HISTORY: (If this section has no content, then delete the whole section.)
- [Relevant family history background]
VACCINATION HISTORY: (If this section has no content, then delete the whole section.)
- [Relevant immunisation history background]
PHYSICAL EXAMINATION:
Vitals: (If any vitals have no value then don't print that item.) (If this section has no content, then delete the whole section.)
- [Weight] (If no weight is provided then don't print this item.)
- [Blood sugar level]
- [Ketones]
- [Temperature]
- [Blood pressure]
- [Heart rate] (Write heart rate as a value /minute, eg. 80 beats/minute.)
- [Oxygen saturation]
General: [General appearance and status] (If there is no content delete this item.)
CVS: [Cardiovascular examination findings] (Do not start a new line for each finding.) (If there is no content delete this item.)
Resp: [Respiratory examination findings] (If there is no content delete this item.)
Abdo: [Abdominal examination findings] (If there is no content delete this item.)
Neuro: [Neurological examination findings] (If there is no content delete this item.)
MSK: [Musculoskeletal examination findings] (If there is no content delete this item.)
INVESTIGATIONS: (Write this heading in all capitals.) (If this section has no content, then delete the whole section.)
Bloods:
- [Relevant blood test results]
Microbiology:
- [Relevant microbiology results.]
Radiology:
- [Relevant radiology results]
[Additional investigations and findings]
EVALUATION:
- [Primary diagnosis]
- [Secondary diagnoses or issues]
EMERGENCY MANAGEMENT: (If this section has no content, then delete the whole section.)
- [Details of treatment provided in Emergency Department today]
- [Outcome of treatment provided in Emergency Department today]
PLAN: (Write this heading in all capitals.)
- [Admission plan and team assignment]
- [Dietary instructions]
- [Fluid management plan]
- [Medication orders]
- [Consults and referrals]
- [Monitoring instructions]
- [Disposition plan]
Sample Clinical Note

Example of completed documentation using this template

REASON FOR PRESENTATION:
- Chest discomfort and difficulty breathing
HISTORY OF PRESENTING ILLNESS:
- Symptom onset: 2 hours prior
- Symptom description: Intense, crushing chest pain extending to the left arm
- Additional symptoms: Nausea and perspiration
- Potential triggers or exposures: Physical activity
- Relevant background: History of high blood pressure
REVIEW OF SYSTEMS:
- Cardiovascular: No palpitations, no prior chest pain episodes
- Respiratory: No cough, no wheezing
MANAGEMENT EN ROUTE WITH QAS:
- Treatment details by QAS Ambulance enroute to Hospital: Administered oxygen therapy and aspirin
- Treatment outcome by QAS Ambulance enroute to Hospital: Partial symptom relief
PAST MEDICAL HISTORY:
- High blood pressure
- Appendectomy in 2010
MEDICATIONS:
- Lisinopril 10 mg daily
ALLERGIES:
- Penicillin
SOCIAL HISTORY:
- Lives alone, employed as a construction worker
DRUG, TOBACCO, ALCOHOL HISTORY:
- Alcohol: Social consumption
- Tobacco: Smokes 10 cigarettes daily
FAMILY HISTORY:
- Father experienced a heart attack at age 55
IMMUNISATION HISTORY:
- Vaccinations are current
EXAMINATION:
Vitals:
- Blood pressure: 150/90 mmHg
- Heart rate: 95 beats/minute
- Oxygen saturation: 94% on room air
General: Alert, experiencing mild distress
CVS: Regular heart sounds, no murmurs
Resp: Clear breath sounds on both sides
Abdo: Soft, non-tender
Neuro: No focal neurological deficits
INVESTIGATIONS:
Bloods:
- Troponin: Elevated
Radiology:
- Chest X-ray: No acute findings
ASSESSMENT:
- Primary diagnosis: Acute coronary syndrome
- Secondary diagnoses or issues: High blood pressure
MANAGEMENT IN EMERGENCY:
- Treatment details in Emergency Department today: Administered nitroglycerin and morphine
- Treatment outcome in Emergency Department today: Significant chest pain relief
PLAN:
- Admission plan and team assignment: Admit to Cardiology
- Dietary instructions: Cardiac diet
- Fluid management plan: IV fluids as required
- Medication orders: Continue aspirin, initiate beta-blocker
- Consults and referrals: Cardiology consultation
- Monitoring instructions: Continuous cardiac monitoring
- Disposition plan: Transfer to Cardiology unit
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template is designed to streamline patient documentation, ensuring that healthcare professionals can efficiently capture critical patient information. With sections covering the reason for presentation, history of presenting illness, and detailed examination findings, this template facilitates thorough patient assessments. It includes areas for past medical history, medications, allergies, and social history, allowing for a holistic view of the patient's health. The template also provides space for documenting management en route with QAS, family history, and immunisation history, ensuring no detail is overlooked. Clinicians can easily record vital signs, examination results, and investigations, leading to accurate assessments and effective management plans. By adopting this template, healthcare providers can enhance clinical workflows, improve patient care, and ensure comprehensive documentation. Explore this template to optimize your clinical practice today.
Frequently Asked Questions

Common questions about this template and its usage

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Emergency Department Documentation