Emergency Department Clerking Template

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.)