ED note *

**PC:** - [Reason for presentation] (short, no more than 5-10 words but include patient age and gender) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) **HISTORY OF PC:** - [Onset of symptoms] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Description of symptoms] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Additional relevant symptoms] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Possible triggers or exposures] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Relevant background information] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) **Back Pain RED FLAGS:** (If these findings have been mentioned in section above do not repeat here.) (If this section has no content, then delete the whole section.) (Please explicitly include the below if mentioned, rather than just "urinary symptoms" for example.) No weakness No bladder dysfunction, has full control, no LUTs No bowel problems No unexplained weight loss No trauma/injury No central back pain No fevers No IVDU No immunosuppression No hx of malignancy No saddle paraesthesia **SYSTEMS REVIEW:** (If these findings have been mentioned in section above do not repeat here.) (If this section has no content, then delete the whole section.) (Please explicitly include the below if mentioned, rather than just "urinary symptoms" for example.) - [Relevant positive and negative findings from system-specific review: Nil dizziness, headache, visual disturbance. Nil runny nose, colds, fevers. Nil cough, shortness of breath. Nil chest pain, palpitations, orthopnoea. Nil nausea, vomiting, diarrhoea, constipation, abdominal pain. Nil dysuria, frequency, change in urine volume / colour / smell. Nil swelling, redness, pain in legs.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) **MANAGEMENT EN ROUTE WITH NSWAS:** (If this section has no content, then delete the whole section.) - [Details of treatment provided by NSW Ambulance enroute to Hospital.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Outcome of treatment provided by NSW Ambulance enroute to Hospital.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) **MEDICAL HX:** (Write each new issue on a new line.) (If this section has no content, then delete the whole section.) - [Relevant medical conditions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Relevant surgical history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Relevant mental health history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Specialist involvement] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) **MEDICATIONS:** (If this section has no content, then delete the whole section.) - [Current medications and dosages] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) **ALLERGIES:** (If this section has no content, then delete the whole section.) - [Known drug allergies] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) **SOCIAL HX:** (If this section has no content, then delete the whole section.) - [Relevant social background] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Relevant alcohol history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Relevant tobacco history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Relevant social drug use history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) **FAMILY HISTORY:** (If this section has no content, then delete the whole section.) - [Relevant family history background] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) **IMMUNISATION HISTORY:** (If this section has no content, then delete the whole section.) - [Relevant immunisation history background] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) **EXAMINATION:** Vitals: (If any vitals have no value then don't print that item.) (If this section has no content, then delete the whole section.) - [Weight] (If no weight is provided then don't print this item.) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Blood sugar level] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Ketones] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Temperature] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Blood pressure] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Heart rate] (Write heart rate as a value /minute, eg. 80 beats/minute.) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Oxygen saturation] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) [General appearance and status] (If there is no content delete this item.) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) [Cardiovascular examination findings] (Do not start a new line for each finding.) (If there is no content delete this item.) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) [Respiratory examination findings] (If there is no content delete this item.) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) [Abdominal examination findings] (If there is no content delete this item.) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) [Neurological examination findings] (If there is no content delete this item.) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) [Musculoskeletal examination findings] (If there is no content delete this item.) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) [Additional examination findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) **INVESTIGATIONS:** (If this section has no content, then delete the whole section.) Bloods: - [Relevant blood test results] CG4 / VBG (only include if GC4 / VBG / blood gas or its component below are explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - pH [result] - CO2 [result] - BE [result] - HCO3 [result] - Lac [result] Chem8 (only include if Chem8 or its component below are explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - Na [result] - K [result] - Gluc [result] - Creat [result] - Hb [result] iSTAT Troponin - [result] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Microbiology: - [Relevant microbiology results.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Radiology: - [Relevant radiology results] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) [Additional investigations and findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) **IMPRESSION:** - [Primary diagnosis] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Secondary diagnoses or issues] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) **PROGRESS MANAGEMENT IN EMERGENCY:** (If this section has no content, then delete the whole section.) - [Details of treatment provided in Emergency Department today] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Outcome of treatment provided in Emergency Department today] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Results of further investigations in Emergency Department today ie repeat troponin or bedside US] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) **PLAN:** - [Disposition plan including location (ie home vs ward vs CHHC) and method of transport if relevant] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Admission plan and team assignment] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Dietary instructions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Fluid management plan] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Medication orders] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Discharge instructions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Follow-up plan including outpatient investigations] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Consults and referrals either inpatient or outpatient] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Monitoring instructions for clinical staff or patient, and who / when to contact if concerns] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) [Insert Clinician Name Placeholder] [Insert Role Placeholder, e.g., ED CMO / ACRRM Trainee] (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 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, depending on the format, as needed to capture all the relevant information from the transcript)