The MDM template for the Emergency Department by s10.ai is crafted for Emergency Medicine Specialists to streamline the documentation of patient interactions in the ER. This template aids healthcare providers in concisely summarizing the visit's purpose, reassessment outcomes, and patient management plans, including treatment strategies, follow-up scheduling, and educational guidance. It guarantees thorough documentation of essential details, promoting efficient communication and informed decision-making. This tool is especially beneficial for capturing the fast-paced environment of emergency care, where swift evaluations and collaborative decision-making are vital. Perfect for emergency medicine documentation, it improves the precision and thoroughness of medical records.
Organized sections for comprehensive clinical documentation
Example of completed documentation using this template
Patient is a 45-year-old male who arrived at the emergency department with complaints of intense abdominal pain and nausea. His medical history includes hypertension and type 2 diabetes. Upon examination, tenderness was noted in the right lower quadrant. Laboratory tests indicated leukocytosis, and a CT scan of the abdomen revealed findings consistent with appendicitis.Reassessment:- The patient's abdominal pain has lessened after receiving analgesics.- Lab results and imaging were reviewed with the patient, and the subsequent steps were mutually agreed upon.- Shared decision-making was employed to ensure the patient was comfortable and agreeable with the discharge plan.Plan for Patient:- The patient is scheduled for an appendectomy later today.- A follow-up appointment with the surgeon is set for 7 days after the operation.- The patient was informed about post-operative care and signs of infection to monitor.- No changes to medication were made at this time.- Advised to follow a light diet post-surgery and increase fluid intake.
Key advantages of using this template in clinical practice
Common questions about this template and its usage