ED Assessment AEC

ED Reg [name of ED reg] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. If the consult takes place between 0100 and 0800, print "Discussed with snr reg" on a new line. Otherwise, print "Discussed with SMO" on a new line.) PC/ [brief description of presenting complaint] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) HPC/ [relevant history of presenting complaint] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) [specific symptoms reported by the patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) [pertinent negatives relevant to the presenting complaint] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) [general condition of the patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) PMH/ [relevant past medical history] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) DH/ [current medications including drug name, dose and frequency] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write as a bullet point list.) Allergies: [allergies including allergen and reaction type] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else print "NKDA". Write as a bullet point list.) SH/ [who the patient lives with] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) [type of accommodation the patient lives in] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) [smoking status] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) [alcohol consumption] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) [recreational drug use] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) [functional baseline] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) O/E/ Vitals: [vital signs] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely. Write each vital sign on its own line.) Chest: [chest examination findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) Abdo: [abdominal examination findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) Neuro: [neurological examination findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) Lower limbs: [lower limb examination findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) Upper limbs: [upper limb examination findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) Investigations/ VBG: [VBG results and interpretation] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) Bloods: [blood test results] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) ECG: [ECG findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) CXR: [chest X-ray findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) Other imaging: [findings from any other imaging performed] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) IMP/ [summary of clinical impression] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) [red flags or clinical concerns] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) PLAN/ "D/w snr" [discussion with patient and/or family and the agreed management plan] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) [education provided to patient and/or family] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) [follow-up arrangements] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) [red flags discussed and criteria for returning to the emergency department] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.) [further investigations required] (Only include if explicitly mentioned in transcript, contextual notes or clinical notes, else omit section entirely.)