Emergency Medicine Specialist Template

Emergency Department Clerking Template

A professional Emergency Medicine Specialist template for healthcare professionals.

About this template

Need a quick and comprehensive way to document patient encounters in the Emergency Department? This Emergency Department Clerking Template is designed for Emergency Medicine Specialists. It helps you efficiently record presenting complaints, medical history, examination findings, investigations, diagnosis, and management plans. With Heidi, this template can be quickly populated from a visit transcript, saving you valuable time and ensuring thorough documentation. Get your notes done faster and more accurately with this essential template.

Preview template

Emergency Department Clerking Template Emergency Medicine Specialist Presenting Complaint: Patient presents with sudden onset of severe chest pain, radiating to the left arm, and shortness of breath. Symptoms began approximately 30 minutes prior to arrival. (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) History of Presenting Complaint: Patient reports the chest pain is crushing in nature, rated 9/10 in severity. Associated symptoms include diaphoresis, nausea, and lightheadedness. No recent strenuous activity or trauma. (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) Past Medical History: Hypertension, Hyperlipidemia. No prior cardiac history. (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Medications: Lisinopril 20mg daily, Atorvastatin 40mg daily. (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Allergies: NKDA (No Known Drug Allergies) (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely including header.) Social History: Patient is a non-smoker, drinks alcohol occasionally, denies illicit drug use. Works as an accountant. Lives with his wife. (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Family History: Father had a history of myocardial infarction at age 65. Mother has hypertension. (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) On Examination: * Vital Signs: BP 160/90 mmHg, HR 110 bpm, RR 24, SpO2 94% on room air, Temp 37.1°C. * General: Appears anxious and in distress. * Cardiovascular: Regular rhythm, S1S2, no murmurs, rubs, or gallops. * Respiratory: Mildly labored breathing, clear to auscultation bilaterally. * Other systems: Unremarkable. (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Investigations: * ECG: ST-segment elevation in leads II, III, and aVF. * Cardiac Enzymes: Troponin I elevated. * Chest X-ray: Within normal limits. * Blood tests: CBC, CMP, Coags ordered. (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Impression/Diagnosis: Acute Myocardial Infarction (STEMI). (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Management Plan: * Administered aspirin 325mg, oxygen via nasal cannula. * IV access established. * Called cardiology for immediate intervention. * Morphine 2mg IV for pain control. * Continuous cardiac monitoring. * Patient to be transferred to the cardiac catheterisation lab. (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Disposition: Patient transferred to the cardiac catheterisation lab for percutaneous coronary intervention (PCI). Condition stable at the time of transfer. (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)

Presenting Complaint: [describe the main reason for the patient's visit to the emergency department, including symptoms and duration] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) History of Presenting Complaint: [provide a detailed history of the presenting complaint, including onset, progression, associated symptoms, and any relevant context or events leading up to the visit] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) Past Medical History: [document any relevant past medical history, including chronic illnesses, previous hospitalisations, and surgeries] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Medications: [list all current medications, including dosages and over-the-counter supplements] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Allergies: [mention any known allergies, including drug, food, and environmental allergies] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely including header.) Social History: [describe relevant social history, including smoking status, alcohol consumption, drug use, occupation, and living situation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Family History: [document any relevant family medical history, including hereditary conditions and illnesses] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) On Examination: [provide detailed findings from the physical examination, including vital signs, general appearance, and specific system examinations] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Investigations: [list any investigations ordered or performed, including blood tests, imaging studies, and other diagnostic tests, along with their results if available] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Impression/Diagnosis: [document the clinical impression or diagnosis based on the history, examination, and investigations] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Management Plan: [outline the management plan, including any treatments administered in the emergency department, medications prescribed, referrals made, and follow-up instructions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Disposition: [describe the patient's disposition, including whether they were discharged, admitted, or transferred, and any relevant details about their condition at the time of disposition] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) (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. Suppose any information related to a placeholder has not been explicitly mentioned in the transcript. In that case, 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.)

Browse more templates

Use this template