Emergency Progress Note

Introduction: [Patient’s age and gender] [Patient’s origin, e.g. school or home] [Mode of transport to ED] [Accompanying parent or specify "unaccompanied"] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Issues List: - [Description of clinical issue, symptom or concern] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a brief description.) - [Key takeaways or recommendations related to the issue, including advice or plan of action] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a brief summary.) (Repeat bullet point structure for as many issues as needed.) Progress: - [Progress review following initial treatment, including changes in symptoms or observations] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as bullet points.) - [Discussions with patient, parent, or other involved parties regarding care] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as bullet points.) Physical Examination: - Vital Signs: [BP, HR, RR, Temp, SpO2] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line followed by CEWT score.) - CEWT Score: [Score] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) - General: [General state of health and notable findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) - Airway: [Airway patency, oxygen use or support] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) - Breathing: [Breath sounds, work of breathing, wheeze, crackles etc.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) - Cardiovascular: [Heart rhythm, murmurs, perfusion, capillary refill, pulses] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) - Disability: [GCS, BGL, behavioural findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) - ENT: [Ear, nose, throat findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) - Abdo: [Findings on abdominal exam – observation, palpation, tenderness etc.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) - MSK: [Musculoskeletal findings including ROM, strength, deformity] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) - Neuro: [Mental state, fontanelles (if paediatric), cranial nerves, coordination, reflexes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Investigations: - Pathology: [Bloods, urine, respiratory swabs, or other lab results] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) - Imaging: [X-rays, CTs, MRIs] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) - Other: [ECG, ultrasound, or other diagnostic tests] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Assessment/Impression: - [Working or presumed diagnosis] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) - [Clinical rationale for impression] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in one full sentence.) - [Differential diagnosis] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) Plan/Treatment: - Immediate Management: [Treatments administered in ED] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) - Investigations: [Planned diagnostics or follow-up tests] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) - Referrals: [Any referrals made, including internal or external] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) - Discharge & Follow-Up: [Instructions for care at home, GP review, specialist follow-up etc.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single line.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care – use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)