Emergency Medicine Specialist-Vorlage
General ED Note_ES
Eine professionelle Emergency Medicine Specialist-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
Need to quickly document a patient's visit to the Emergency Department? This General ED Note template is designed for Emergency Medicine Specialists to efficiently record patient information, from presenting complaints and vital signs to diagnoses and treatment plans. This template ensures all critical details are captured, helping you create comprehensive medical records. With Heidi, the AI scribe, this template can be automatically populated from your patient encounter, saving you time and improving accuracy. Use this template to create detailed and accurate medical documentation for your ED patients.
Vorlagenvorschau
Age: 34yo
Gender: Male
No allergies known
Not applicable
Hypertension
Appendectomy 10 years ago.
Lisinopril 20mg daily.
Smoker, 10 cigarettes per day. Drinks alcohol occasionally. Works as a software engineer. Lives in a flat with his partner.
Father with history of myocardial infarction at age 60.
Now c/o:
Chest pain for the past 2 hours.
- DOI 01/11/2024 14:00
- MOI Not applicable
Sudden onset, sharp chest pain, radiating to left arm. Associated with shortness of breath and diaphoresis.
No fever, no cough, no recent illness.
Lisinopril 20mg daily.
Diaphoresis.
Not applicable.
Not applicable.
Chest pain, shortness of breath, palpitations.
Shortness of breath.
Not applicable.
Not applicable.
Not applicable.
Not applicable.
Not applicable.
Not applicable.
Not applicable.
Not applicable.
Not applicable.
Not applicable.
Vitals:
BP 160/90 mmHg, HR 110 bpm, RR 24 bpm, Sats 94%, RA, T 37.1°C
Hb: Not mentioned
Hgt: Not mentioned
Udip: Not mentioned
Urine prognostic: Not mentioned
Examination:
GEN: Appears in distress, diaphoretic.
CNS: No abnormal findings.
ENT: No abnormal findings.
RESP: Bilateral equal air entry, no wheezes or crackles.
CVS: Tachycardic, regular rhythm, no murmurs.
ABD: Soft, non-tender.
GYN: Not applicable.
OBS: Not applicable.
GU: Not applicable.
MSK: Not applicable.
DERM: Not applicable.
PSYCH: Not applicable.
OPTHAL: Not applicable.
ICD-10 diagnosis codes: I21.9, R07.9
Assessment:
Acute Myocardial Infarction
Stable
Not applicable
Hypertension
DOI 01/11/2024 14:00
MOI Not applicable
Differential:
Acute Coronary Syndrome, Angina, Pericarditis.
Plan:
IV access established. 0.9% Saline bolus.
Aspirin 300mg PO, Morphine 2mg IV, Oxygen via nasal prongs.
ECG, Cardiac enzymes, CXR.
Not applicable
CBC, CMP, Troponin.
Cardiology consult.
Discussed risks and benefits of treatment with patient.
Discussed with patient.
Cardiology consulted.
Admitted to CCU.
Cardiology follow up.
Not applicable
Repeat cardiac enzymes in 3 hours.
Reviewed by cardiology.
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