Accident and Emergency Nurse Template

ISOBAR

A professional Accident and Emergency Nurse template for healthcare professionals.

About this template

Need a quick and efficient way to document patient care in the A&E? The ISOBAR template is a structured clinical note template designed for Accident and Emergency Nurses. This template helps you capture essential patient information, from the initial presentation to the recommendations, ensuring a clear and concise record. With Heidi, this template can be automatically populated from your patient visit transcript, saving you time and improving accuracy. Get your documentation done faster with this essential tool.

Preview template

Introduction: - 32 - Female Situation: - Patient presents with a laceration to the left forearm after falling on broken glass. - The laceration occurred approximately 30 minutes prior to presentation. It is located on the volar aspect of the left forearm, approximately 5cm in length and 1cm deep. The patient reports significant pain, described as a sharp, throbbing sensation, rated 7/10. There is active bleeding. - Applying direct pressure to the wound has slightly reduced the bleeding. - No change in symptoms since the injury occurred. - No previous similar injuries. - The injury is affecting the patient's ability to use their left arm. - No other associated symptoms. Background: - No significant past medical history. No known allergies. Tetanus vaccination status unknown. - Patient is a non-smoker and denies alcohol or drug use. Works as a software engineer. - No family history of bleeding disorders. - No known exposures. - Immunization history unknown. - Other: Patient is anxious about the injury. Assessment: - BP: 130/80 mmHg, HR: 100 bpm, RR: 18, SpO2: 98% on room air, Temp: 37.1°C. - Examination of the left forearm reveals a 5cm laceration with active bleeding. Neurovascular status is intact distally. No signs of infection. - None. Recommendation: [1. Laceration to left forearm] - Laceration - None - X-ray of the left forearm to rule out fracture. - Wound irrigation, exploration, and suturing. Administer tetanus toxoid. Provide analgesia. - Refer to plastic surgery if the wound requires further intervention. [2. Anxiety] - Anxiety - None - None - Provide reassurance and emotional support. - None

Introduction: - [Age of patient] - [Gender of patient] Situation: - [Mention reasons for visit, chief complaints such as requests, symptoms etc] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - [Mention Duration/timing/location/quality/severity/context of complaint] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - [Mention List anything that worsens or alleviates the symptoms, including self-treatment attempts and their effectiveness] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - [Progression: Mention describe how the symptoms have changed or evolved over time] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - [Previous episodes: Mention detail any past occurrences of similar symptoms, including when they occurred, how they were managed, and the outcomes] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - [Mention Impact on daily activities: explain how the symptoms affect the patient's daily life, work, and activities.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - [Associated symptoms: Mention any other symptoms (focal and systemic) that accompany the reasons for visit & chief complaints] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) Background: - [Mention Contributing factors including past medical and surgical history, investigations, treatments, relevant to the reasons for visit and chief complaints] - [Mention Social history that may be relevant to the reasons for visit and chief complaints.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - [Mention Family history that may be relevant to the reasons for visit and chief complaints.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - [Mention Exposure history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - [Mention Immunization history & status] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) - [Other: Mention Any other relevant subjective information] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank) Assessment: - [Vitals signs (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] - [Physical or mental state examination findings, including system specific examination(s) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] - [Investigations with results] (you must only include completed investigations and the results of these investigations have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise you must leave investigations with results blank. All planned or ordered investigations must not be included under Objective; instead all planned or ordered investigations must be included under Plan.) Recommendation: [1. Issue, problem or request 1 (issue, request, topic or condition name only)] - [Assessment, likely diagnosis for Issue 1 (condition name only; only include if different to the issue, problem or request in the line above; if they're the same, omit this line completely)] - [Differential diagnosis for Issue 1 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] - [Investigations planned for Issue 1 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] - [Treatment planned for Issue 1 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] - [Relevant referrals for Issue 1 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] [2. Issue, problem or request 2 (issue, request, topic or condition name only)] - [Assessment, likely diagnosis for Issue 2 (condition name only; only include if different to the issue, problem or request in the line above; if they're the same, omit this line completely)] - [Differential diagnosis for Issue 2 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] - [Investigations planned for Issue 2 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] - [Treatment planned for Issue 2 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] - [Relevant referrals for Issue 2 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] [3. Issue, problem or request 3, 4, 5 etc (issue, request, topic or condition name only)] - [Assessment, likely diagnosis for Issue 3, 4, 5 etc (condition name only; only include if different to the issue, problem or request in the line above; if they're the same, omit this line completely)] - [Differential diagnosis for Issue 3, 4, 5 etc (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] - [Investigations planned for Issue 3, 4, 5 etc (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] - [Treatment planned for Issue 3, 4, 5 etc (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] - [Relevant referrals for Issue 3, 4, 5 etc (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)] (Never come up with your own assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note.) (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.)

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