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Emergency Medicine Physician
20-25 minutes

Instructions for Discharge from the Emergency Department

Emergency Department Discharge Instructions are essential for ensuring patients fully comprehend their diagnosis, treatment plan, and necessary follow-up care post-emergency visit. This template, crafted for Emergency Medicine Specialists, offers clear and thorough discharge instructions. It encompasses sections for diagnosis, test results, treatments provided, prescribed medications, return precautions, patient education, and follow-up care. Utilizing s10.ai, this template guarantees precise capture and communication of all vital information, thereby improving patient safety and adherence. This template is perfect for generating detailed and patient-centric discharge notes in emergency care environments.

3,509 uses
4.6/5.0
A
Austin-John Thompson
Template Structure

Organized sections for comprehensive clinical documentation

Diagnosis:
- [detail the diagnosis and/or clinical impression] (only include if explicitly mentioned in the transcript, additions, contextual notes or clinical note, otherwise leave blank.)
Results:
- [detail test results, imaging findings, lab results, etc.] (only include if explicitly mentioned in the transcript, additions, contextual notes or clinical note, otherwise leave blank.)
Treatment:
- [detail treatment provided in the ED, including medications administered, procedures performed, etc.] (only include if explicitly mentioned in the transcript, additions, contextual notes or clinical note, otherwise leave blank.)
Prescribed Medications:
- [enumerate all medications prescribed during discharge, include the dosage and administration frequency, list pertinent and/or common side effects to monitor, list recommendations for medication administration such as eat with a meal, or take on an empty stomach, or drink plenty of water, etc.] (you may offer suggestions based off patients diagnosis if not already explicitly mentioned in the transcript, additions, contextual notes or clinical note.)
Return Precautions:
Return to the Emergency Department if you experience any of the following:
- [enumerate specific symptoms or signs that warrant a return visit based off of the patients diagnosis and/or clinical impression.]
Patient Education:
- [offer patient education related to the diagnosis, including lifestyle modifications, medication instructions, etc.]
Follow-Up Care:
- Follow up with your primary care provider or specialist as recommended.
- [specify follow-up care instructions, including appointments, referrals, and any additional tests or treatments needed] (only include if explicitly mentioned in the transcript, additions, contextual notes or clinical note, otherwise leave blank.)
Sample Clinical Note

Example of completed documentation using this template

Diagnosis:  
- Acute appendicitis  
Results:  
- Abdominal CT scan revealed an inflamed appendix with surrounding fluid accumulation.  
Treatment:  
- Administered IV antibiotics and conducted an appendectomy.  
Prescribed Medications:  
- Amoxicillin 500 mg, take one tablet every 8 hours for 7 days. Possible side effects include nausea and diarrhea. Take with food to reduce stomach upset.  
- Acetaminophen 500 mg, take one tablet every 6 hours as needed for pain. Do not exceed 4 grams in 24 hours.  
Return Precautions:  
Return to the Emergency Department if you experience any of the following:  
  - Severe abdominal pain  
  - Fever over 101°F  
  - Persistent vomiting  
  - Signs of infection at the surgical site, such as redness or pus  
Patient Education:  
- Avoid heavy lifting and strenuous activities for at least 2 weeks after surgery.  
- Maintain a balanced diet and stay hydrated to support recovery.  
Follow-Up Care:  
- Follow up with your primary care provider in 1 week for a post-operative check-up.  
- Referral to a dietitian for nutritional guidance if needed.
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template is designed to streamline emergency department documentation, ensuring accurate and efficient patient care. It includes sections for diagnosis, test results, and treatment details, allowing clinicians to capture critical information swiftly. The template also provides a structured format for prescribing medications, complete with dosage, administration guidelines, and potential side effects, enhancing patient safety and compliance. Return precautions are clearly outlined, guiding patients on when to seek further medical attention. Additionally, the template offers valuable patient education resources, promoting lifestyle modifications and medication adherence. Follow-up care instructions are included to facilitate continuity of care, ensuring patients receive necessary referrals and additional testing. By adopting this template, healthcare professionals can improve documentation accuracy, enhance patient outcomes, and optimize clinical workflows.
Frequently Asked Questions

Common questions about this template and its usage

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