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Emergency Medicine Physician
25-30 minutes

Template for Emergency Medicine Clerking

The s10.ai Emergency Medicine Clerking template is an all-encompassing resource crafted for emergency medicine professionals to streamline patient encounter documentation. This template meticulously addresses every vital component of patient evaluation, such as chief complaints, history of presenting complaints, associated symptoms, past medical history, and examination findings. Additionally, it features dedicated sections for investigations, differential diagnosis, and management plans. Perfectly suited for emergency departments, this template ensures rapid and comprehensive documentation, empowering clinicians to enhance patient care and operational efficiency. Explore the s10.ai template today to elevate your emergency medicine practice.

4,143 uses
4.8/5.0
D
Dr. Emily Chen
Template Structure

Organized sections for comprehensive clinical documentation

1. Primary Concern:
[Patient's main concern in their own words]
2. History of Current Issue:
[Comprehensive description of the current issue, including onset, duration, characteristics, and any pertinent context]
3. Related Symptoms:
[List of related symptoms]
4. Medical History:
Chronic Conditions: [List any chronic conditions]
Previous Surgeries: [List any previous surgeries]
Previous Episodes: [Any relevant previous episodes related to current issue]
5. Medication History:
Current Medications: [List all current medications, including dosages and frequency]
Allergies: [List any known allergies and reactions]
6. Social History:
Smoking: [Current status and history]
Alcohol Use: [Current status and frequency]
Drug Use: [Any relevant drug use history]
Living Situation: [Who the patient lives with, independent or dependent in daily activities]
7. System Review:
General: [Weight loss, fever, fatigue, etc.]
Cardiovascular: [Chest pain, palpitations, etc.]
Respiratory: [Cough, shortness of breath, etc.]
Gastrointestinal: [Nausea, vomiting, diarrhea, etc.]
Neurological: [Headaches, dizziness, etc.]
Musculoskeletal: [Joint pain, swelling, etc.]
Skin: [Rashes, lesions, etc.]
8. Examination Results:
Vital Signs:
Temperature: [°C]
Heart Rate: [bpm]
Respiratory Rate: [breaths/min]
Blood Pressure: [mmHg]
Oxygen Saturation: [%]
General Appearance: [Patient's overall appearance]
Head and Neck: [Findings]
Chest/Lungs: [Auscultation findings]
Heart: [Heart sounds, murmurs]
Abdomen: [Tenderness, distension, bowel sounds]
Extremities: [Edema, pulses]
Neurological: [GCS, motor/sensory findings]
9. Diagnostic Tests:
Laboratory Tests: [Results of any lab tests performed]
Imaging Studies: [Results of any imaging studies performed]
ECG Findings: [Results of ECG if performed]
10. Assessment and Differential Diagnosis:
[Clinical assessment and differential diagnoses based on findings]
11. Management Plan:
Immediate Management: [Any immediate treatments provided]
Further Investigations: [Any additional tests to be performed]
Consultations: [Referrals to specialists if needed]
Discharge Instructions: [Instructions for follow-up care, medications, when to return]
Follow-Up: [Specify when and how the patient should follow up]
Sample Clinical Note

Example of completed documentation using this template

1. Chief Complaint:  
"Intense abdominal pain and nausea."
2. History of Presenting Complaint:  
The patient describes a sudden onset of intense abdominal pain that started about 6 hours ago. The pain is characterized as sharp and persistent, located in the lower right quadrant. The patient also mentions nausea and has vomited twice since the pain began.
3. Associated Symptoms:  
- Nausea  
- Vomiting  
- Loss of appetite  
4. Past Medical History:  
Chronic Conditions: Hypertension  
Previous Surgeries: Appendectomy 5 years ago  
Previous Episodes: None related to current complaint  
5. Medication History:  
Current Medications: Lisinopril 10 mg once daily  
Allergies: Penicillin (rash)  
6. Social History:  
Smoking: Non-smoker  
Alcohol Use: Occasional, 1-2 drinks per week  
Drug Use: Denies any illicit drug use  
Living Situation: Lives alone, independent in daily activities  
7. Review of Systems:  
General: No recent weight loss, fever, or fatigue  
Cardiovascular: No chest pain or palpitations  
Respiratory: No cough or shortness of breath  
Gastrointestinal: Nausea, vomiting, no diarrhea  
Neurological: No headaches or dizziness  
Musculoskeletal: No joint pain or swelling  
Skin: No rashes or lesions  
8. Examination Findings:  
Vital Signs:  
- Temperature: 37.8°C  
- Heart Rate: 98 bpm  
- Respiratory Rate: 18 breaths/min  
- Blood Pressure: 130/85 mmHg  
- Oxygen Saturation: 98%  
General Appearance: Patient appears in mild distress due to pain  
Head and Neck: No abnormalities noted  
Chest/Lungs: Clear to auscultation bilaterally  
Heart: Regular rate and rhythm, no murmurs  
Abdomen: Tenderness in the lower right quadrant, no distension, normal bowel sounds  
Extremities: No edema, pulses intact  
Neurological: Alert and oriented, no focal deficits  
9. Investigations:  
Laboratory Tests: Elevated white blood cell count  
Imaging Studies: Abdominal ultrasound shows possible gallstones  
ECG Findings: Normal sinus rhythm  
10. Impression and Differential Diagnosis:  
Clinical impression suggests possible cholecystitis. Differential diagnoses include pancreatitis and peptic ulcer disease.
11. Plan:  
Immediate Management: Administered IV fluids and analgesics  
Further Investigations: CT scan of the abdomen to confirm diagnosis  
Consultations: Referral to general surgery for further evaluation  
Discharge Instructions: Advised to avoid fatty foods, prescribed antiemetics, and instructed to return if symptoms worsen  
Follow-Up: Follow-up with primary care physician in 3 days
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 and review critical patient information. By incorporating high-search healthcare and clinical keywords, this template enhances the accuracy and completeness of medical records, facilitating better patient care and communication among multidisciplinary teams. Clinicians can easily document the chief complaint, detailed history of presenting issues, associated symptoms, and past medical history, including chronic conditions and previous surgeries. The template also allows for thorough medication and social history documentation, as well as a detailed review of systems and examination findings. With sections dedicated to investigations, clinical impressions, and management plans, this template supports informed decision-making and continuity of care. Explore and implement this template to optimize clinical workflows and improve patient outcomes.
Frequently Asked Questions

Common questions about this template and its usage

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Template for Emergency Medicine Clerking