ED Note

[patient age and gender] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) [context of presentation, such as location of assessment and mode of arrival] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. List as single sentences on separate lines.) Chief Complaint: [brief statement of patient's primary concern or reason for presentation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) History of Presenting Complaint: [detailed narrative of current illness including onset, duration, character, associated symptoms, aggravating and relieving factors] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. List as bullet points.) [pertinent negative symptoms] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. List as bullet points.) Past Medical History: [relevant previous medical conditions, surgeries, hospitalizations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. List as bullet points.) Medications: [current medications including dosages] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. List as bullet points.) Allergies: [known allergies and reactions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. List as bullet points.) Social History: [smoking, alcohol, recreational drugs, occupation, living situation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) Family History: [relevant family medical history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) Examination: A - Airway: [airway assessment findings including patency, obstruction, protection] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) B - Breathing: [respiratory assessment including rate, effort, oxygen saturation, chest examination findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) C - Circulation: [cardiovascular assessment including heart rate, blood pressure, pulse quality, capillary refill, cardiac examination] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. Use standard abbreviations for vitals where appropriate, for example Hr, BP, CRT.) D - Disability: [neurological assessment including consciousness level, pupil response, motor function, sensation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) E - Exposure: [full body examination findings including temperature, skin assessment, additional relevant findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. Do not include units for temperature.) Investigations: Blood results: [laboratory values with specific parameters and results] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) ECG: [ECG findings and interpretation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) VBG: [venous blood gas results when documented] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) POCUS: [point of care ultrasound findings and interpretation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) Impression: [clinical impression and differential diagnoses] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) Plan: [management plan including treatments, further investigations, disposition] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) Discussion with family - [summary of discussion with family, including goals of care, escalation decisions like DNACPR, who was present, and their understanding and agreement] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely. Write in paragraphs of full sentences.) [clinician name and credentials] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)