EC Initial Assessment

Emergency Centre Initial Presentation: [Insert patient age, gender, and primary reason for presentation] presented to the Emergency Department via [insert mode of arrival, e.g. ambulance, walk-in, police escort] following [insert brief clinical scenario such as injury or illness]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) EC Triage and Initial Observations: [Document triage category, urgency level, mode of arrival, initial vital signs, and any relevant urgency flags or presenting behaviours.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Presenting Complaint: [Detail the main symptoms or issue, including onset, duration, location, severity, and circumstances of onset (e.g. trauma, overdose, mental health event).] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) History of Presenting Illness/Injury: [Expand on symptom progression, associated signs (e.g. fever, vomiting, bleeding), pre-hospital care or medications given, and relevant aggravating/relieving factors.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Past Medical and Surgical History: [Include any relevant chronic conditions, past surgeries, mental health diagnoses, or recent admissions.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Medications: [List current regular medications, including over-the-counter and complementary therapies. Highlight key medications such as anticoagulants, insulin, immunosuppressants, antibiotics, or psychotropics.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Allergies: [Document any known allergies to medications, substances or foods, and the type of reaction.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Social History: [Include relevant lifestyle or contextual information, such as alcohol or drug use, smoking status, living situation, support availability, cognitive status, or risk factors (e.g. domestic violence, safeguarding concerns).] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Clinical Examination: [Summarise physical exam findings relevant to the presentation: general appearance, neurological status, vital signs, cardiovascular, respiratory, abdominal, skin, or musculoskeletal assessments.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Investigations: [List reviewed or ordered investigations such as blood tests, ECG, imaging (e.g. X-ray, CT), urinalysis, toxicology, or bedside diagnostics.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Clinical Impression: [Summarise the working diagnosis, differential diagnoses, or any provisional clinical reasoning.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Never come up with your own assessment or impression.) Plan: [Outline treatment initiated in ED (e.g. analgesia, fluids, sedation), specialist consults, admission/discharge planning, pending investigations or referrals.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Never come up with your own plan or recommendations.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, or plan for continuing care – use only the transcript, contextual notes, or clinical note as a reference for the information to include 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 as needed to capture all relevant information from the transcript.)