Emergency Medicine — General ED Note Template

Patient Identification

Date/Time of arrival: [Date] [Time]
Mode of arrival: Ambulatory / EMS / Wheelchair / Stretcher
Chief complaint: [Primary concern]
Triage acuity: ESI 1 / ESI 2 / ESI 3 / ESI 4 / ESI 5

Triage Information

Triage time: [Time]
Triage vital signs:

• BP: [X/X]
• HR: [X]
• RR: [X]
• Temp: [X]°F / [X]°C
• SpO2: [X]% on [RA / O2 at X L]
• Pain: [X]/10

Triage nurse notes: [Relevant observations]

Chief Complaint

[Primary symptom(s)]
Duration: [Onset, timeline]
Acuity: Acute / Subacute / Chronic / Acute on chronic

History of Present Illness

[Detailed narrative of presenting complaint]
Onset: [When symptoms began]
Location: [Where symptoms are]
Duration: [How long]
Character: [Quality of symptoms]
Aggravating factors: [What makes it worse]
Relieving factors: [What makes it better]
Timing: [Constant, intermittent, pattern]
Severity: [X]/10
Associated symptoms: [Related symptoms]
Negative pertinents: [Important negatives]
Prior similar episodes: None / [Details]
Prior workup: [Relevant testing]
Recent healthcare visits: [ED, urgent care, PCP]
Recent changes: [Medications, activities, exposures]

Review of Systems

Constitutional: [ ] Fever [ ] Chills [ ] Fatigue [ ] Weight change [ ] Night sweats
HEENT: [ ] Headache [ ] Vision changes [ ] Hearing changes [ ] Sore throat [ ] Nasal congestion
Cardiovascular: [ ] Chest pain [ ] Palpitations [ ] Edema [ ] Orthopnea
Respiratory: [ ] Dyspnea [ ] Cough [ ] Wheezing [ ] Hemoptysis
GI: [ ] Nausea [ ] Vomiting [ ] Diarrhea [ ] Constipation [ ] Abdominal pain [ ] Blood in stool
GU: [ ] Dysuria [ ] Frequency [ ] Hematuria [ ] Vaginal/penile discharge
Musculoskeletal: [ ] Joint pain [ ] Muscle pain [ ] Back pain [ ] Weakness
Neurological: [ ] Dizziness [ ] Syncope [ ] Numbness [ ] Tingling [ ] Focal weakness [ ] Seizure
Skin: [ ] Rash [ ] Lesions [ ] Pruritus
Psychiatric: [ ] Depression [ ] Anxiety [ ] Suicidal ideation [ ] Homicidal ideation
All other systems reviewed and negative unless noted above.

Past Medical History

Active conditions: [List]
Prior surgeries: [List with dates]
Hospitalizations: [Recent/relevant]

Medications

[Current medications with doses]
Allergies: [Drug allergies with reactions]

Social History

Tobacco: Current / Former / Never
Alcohol: [Use pattern]
Drugs: [Substances, route]
Living situation: [Home type, who lives with patient]
Occupation: [Relevant to presentation]

Family History

[Relevant family history]

Physical Examination

Time of examination: [Time]
Vital signs:

• BP: [X/X]
• HR: [X] [Regular/Irregular]
• RR: [X]
• Temp: [X]°F / [X]°C
• SpO2: [X]% on [RA / O2]
• Weight: [X] kg

General: [Alert/oriented status, distress level, appearance]
HEENT:

• Head: Normocephalic, atraumatic / [Findings]
• Eyes: PERRL, EOMI / [Findings]
• Ears: TMs clear / [Findings]
• Nose: [Findings]
• Throat: Oropharynx clear / [Findings]

Neck: Supple, no meningismus / [Findings]
Cardiovascular: RRR, no murmurs/rubs/gallops / [Findings]
Respiratory: CTAB, no wheezes/rales/rhonchi / [Findings]
Abdomen: Soft, non-tender, non-distended, +BS / [Findings]
GU: [Deferred / Findings]
Musculoskeletal: [Relevant examination]
Neurological:

• Mental status: [GCS if applicable]
• Cranial nerves: Intact / [Deficits]
• Motor: [Strength assessment]
• Sensory: Intact / [Deficits]
• Coordination: Normal / [Findings]
• Gait: Normal / [Findings] / Not tested

Skin: Warm, dry, no rash / [Findings]
Psychiatric: [Mood, affect, thought process if applicable]

Diagnostic Studies

Laboratory

[ ] CBC: WBC [X], Hgb [X], Plt [X]
[ ] BMP: Na [X], K [X], Cl [X], CO2 [X], BUN [X], Cr [X], Glu [X]
[ ] Troponin: [X]
[ ] BNP: [X]
[ ] Lactate: [X]
[ ] Lipase: [X]
[ ] LFTs: [Values]
[ ] UA: [Findings]
[ ] UCG: Negative / Positive
[ ] Coagulation: PT [X], INR [X], PTT [X]
[ ] Blood cultures: Sent / Not indicated
[ ] Other: [Specify]

Imaging

[ ] CXR: [Interpretation]
[ ] CT [Region]: [Interpretation]
[ ] Ultrasound: [Interpretation]
[ ] X-ray [Region]: [Interpretation]
[ ] Other: [Specify]

Other Studies

[ ] ECG: [Rhythm, rate, intervals, ST changes, interpretation]
[ ] Bedside echo: [If performed]

ED Course

Time in ED: [Duration]
Treatments administered:

• IV fluids: [Type, volume]
• Medications: [Meds given with times]
• Procedures: [If any]

Response to treatment: [Improved / Unchanged / Worsened]
Re-evaluation(s): [Time, findings]
Final vital signs:

• BP: [X/X]
• HR: [X]
• SpO2: [X]%

Medical Decision Making

Differential Diagnosis (Considered)

1) [Most likely diagnosis]
2) [Alternative diagnosis]
3) [Alternative diagnosis]
4) [Ruled out diagnosis]

Data Reviewed/Ordered

[Summary of complexity of data reviewed]

Risk Assessment

Presenting problem: [Low / Moderate / High] risk

• Morbidity/mortality potential: [Assessment]
• Need for additional workup: [Assessment]

Assessment

1) [Primary diagnosis] — [Severity/acuity]
2) [Secondary diagnoses]

Plan

ED Treatment Completed

• [Treatments administered]

Disposition

Disposition: Discharge home / Admit to [Unit] / Transfer to [Facility] / Left AMA / LWBS

If Discharged

Prescriptions:

• [Medication, dose, quantity, refills]

Activity: [Restrictions]
Diet: [Instructions]
Work/school note: [If applicable]
Follow-up:

• PCP: [Timeframe]
• Specialist: [If applicable, timeframe]
• ED return if: [Warning signs]

Patient education provided:

• Diagnosis explained
• Treatment plan discussed
• Warning signs reviewed
• Discharge instructions given: Written / Verbal / Both

If Admitted

Admitting service: [Service]
Attending physician: [Name]
Level of care: Floor / Telemetry / Step-down / ICU
Admission diagnosis: [Diagnosis]
Orders placed:

• [Admission orders summary]

Handoff given to: [Name/service], Time: [Time]

Attestation

Patient examined, history obtained, records reviewed, and management discussed.
Time spent: [Total time if billing time-based]
Critical care time: [Minutes if applicable]
MDM complexity: Straightforward / Low / Moderate / High