Emergency Room Doctors Note with Examples

Emergency Room Doctor’s Note

This emergency room doctor's note template captures comprehensive patient information in emergency medicine settings. It includes sections for past medical history, medication list, history of present illness, physical examination, diagnosis, and plan. Equipped with ambient AI, the template automatically processes information from a clinical encounter, organizing relevant information into corresponding sections.

• Designed with the unique needs of emergency medicine specialists in mind
• Reassessments and updates are easily added after the main note is generated
• Background information (like referrals and investigation results) can be uploaded via the Context tab

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What is an Emergency Room Doctor’s Note?

An emergency room doctor's note documents a patient's emergency department visit, covering details about the presenting complaint, assessment findings, interventions, diagnosis, and treatment plan. ER doctor’s notes serve as the primary medical record of patient encounters in emergency medicine settings. 

Emergency medicine clinicians must provide rapid, often life-saving care to numerous patients in short succession, with minimal downtime for documentation. Many clinicians utilize an emergency room doctor's note template to streamline note-taking processes, as the pre-structured format can enhance information recall, reduce note-taking time, and minimize cognitive load.

In this article, we explore the purpose of an emergency room doctor’s note and common documentation challenges emergency medicine clinicians face. We then look at the benefits of ER doctor’s note templates, explaining how AI-enabled templates can help practitioners create high-quality notes more efficiently.

Purpose of Emergency Room Doctors Notes

An emergency room doctor’s note fulfills several critical functions beyond simply recording what happened during a patient's visit. Understanding these purposes helps busy clinicians to efficiently produce documentation that facilitates high-quality care and meets billing requirements and medicolegal obligations.

Communication and Handover

An ER doctor’s note facilitates effective communication between healthcare providers during a patient's emergency department admission and beyond. Well-structured notes ensure critical information is clearly transmitted between stakeholders like:

• Emergency department staff during shift changes
• Specialists consulting or collaborating on the case
• Inpatient teams accepting transfers of care
• Primary care providers treating discharged patients

In addition to ensuring patient safety,  the information contained in a timely and comprehensive emergency room doctor’s note also supports optimal resource allocation and efficient patient throughput within the hospital.

Coding and Billing

For optimum billing outcomes, emergency physicians must thoroughly document the complexity of assessments, time spent with the patient, input from multidisciplinary team members, and interventions performed. Missing, inadequate, or incorrect information in these areas can lead to reduced or denied reimbursement.

Good emergency room documentation templates support accurate medical coding and billing via prompts that remind clinicians to include pertinent information. They also often utilize a structure familiar to coding and billing staff, minimizing the need for clarification or additional information after the encounter.

Medicolegal Protection

Emergency medicine carries significant liability risks, with clinicians often treating high-acuity patients with limited information on a patient’s background. A comprehensive ER doctor's note can decrease a physician’s medicolegal risk by demonstrating sound clinical reasoning for interventions performed and actions taken (or omitted).

In medicolegal situations, clinical notes created at the time of care are often considered the most critical evidence of the standard of care delivered. Notes written contemporaneously in the ER (or promptly after the encounter) have significantly more credibility than recollections years later when a case may finally reach court.

Research and Quality Improvement

Emergency room doctors’ notes provide valuable data for research and quality improvement initiatives. For example, analyzing documentation patterns might reveal opportunities to improve stroke protocols, trauma response times, or sepsis management in an emergency department.

Incorporating prompts into emergency room documentation templates can improve data collection by signaling to physicians what information is required by researchers and project managers. Prompts can also directly improve care delivery processes, serving as reminders of best practices and evidence-based care pathways.

Challenges with Writing an Emergency Room Doctor’s Note

Due to the fast-paced and high-acuity nature of emergency care, ER physicians face unique documentation challenges. These challenges can place providers under significant stress, often contributing to burnout and job dissatisfaction.

Below is an overview of the top four documentation-related challenges for ER staff, followed by a snapshot of experiences of excessive administrative burden and burnout among emergency medicine physicians.

Short Timeframes

Unlike clinicians in other settings who might have scheduled appointments or the ability to postpone documentation until quieter periods, emergency physicians typically manage multiple patients simultaneously with only minutes to document each encounter.

In the short time available for documentation, the emergency medicine clinician must produce an ER doctor’s note that encapsulates their entire assessment and interventions, while providing a detailed handover to other professionals involved in the patient’s care.

Competing Priorities

Emergency departments function as diagnostic and treatment centers, trauma response units, and safety nets for the wider healthcare and social systems. As a result, emergency physicians constantly struggle to balance urgent clinical demands with departmental flow and documentation requirements.

Understandably, these competing priorities can lead to documentation shortcuts that sometimes result in overly brief or delayed notes. When this occurs, patient safety, physician protection, and reimbursement rates can all be negatively impacted.

High Acuity

Emergency physicians regularly manage life-threatening conditions that require immediate intervention. In these scenarios, documentation often takes a necessary backseat to patient stabilization.

Once the patient is stabilized, the physician must retrospectively document critical details (which may have occurred rapidly and in a high-stress environment). This can lead to unintentional documentation gaps or inaccuracies, particularly regarding the timing of interventions and clinical reasoning.

Standalone Notes

In contrast to clinical settings where progress notes and EMR charting build a patient profile over time, an emergency room doctor’s note often exists as a brief, standalone record. As a result, clinicians must include all relevant information and insights in a single note (or several entries written in short succession), without the luxury of gradually creating a comprehensive picture of the patient’s situation.

The standalone nature of an ER doctor’s note can be a significant source of pressure for emergency medicine clinicians. Providers have only a brief window of opportunity to produce a note, yet their documentation often comes under significant scrutiny for liability and handover purposes.

Stress and Burnout Among ER Clinicians

Emergency medicine clinicians experience some of the highest rates of burnout among medical specialties, with a prevalence as high as 60%.

Factors such as staff shortages, workflow inefficiencies, workplace violence, and moral injury all contribute to burnout among emergency physicians. However, surveys increasingly suggest that administrative burden is a primary driver of burnout in doctors.  

The link between excessive administrative burden and burnout is of significant concern because administrative time is only increasing for emergency physicians. Studies show that ER doctors now spend up to 65% of their time on documentation, with frustration around EHRs also being identified as a contributor to burnout.  

Fed up with clunky, unintuitive EHRs, emergency medicine doctors are increasingly turning to AI to reduce administrative burden. For example, Dr. Nick Lelos, a seasoned emergency medicine doctor, reports that Heidi Health’s AI medical scribe has resulted in a 40% reduction in his daily documentation time.

Note-taking was previously a major bottleneck in Dr. Lelos’ workflow. But now, he explains, “Heidi lets me focus on what matters most—patient care”. 

“It [Heidi] allows you to see more patients, faster, without compromising the quality of your medical notes,” states Dr. Lelos. He also reports reduced cognitive load and mental strain while using the AI scribe, which has improved his work-life balance.

Benefits of Emergency Room Doctors Note Templates

By providing a structured and ready-to-use framework for clinical notes, emergency room documentation templates alleviate many of the documentation challenges ER physicians face. 

The primary benefits of using emergency room doctor’s note templates include:

• Time savings - Pre-populated forms eliminate the need to create standard documentation structures for each patient.
• Enhanced accuracy - Prompts and checkboxes reduce the risk of omitting critical information.
• Greater consistency - Standardized formats improve communication between inpatient and outpatient providers.
• Better compliance - Templates that align with regulatory requirements help ensure documentation meets billing and legal standards.
• Improved clinician well-being - Lower administrative burden and cognitive load often reduces burnout and improves provider well-being. 

When combined with an AI medical scribe like Heidi, the benefits of emergency room doctor’s note templates are further enhanced. AI can automatically populate template sections based on the physician's interaction with the patient, dramatically reducing documentation time while maintaining accuracy and completeness.

Example Emergency Room Doctor’s Note

ER doctor’s note templates can incorporate a variety of structured formats (e.g., SOAP, HPI, review of systems, narrative style). However, each format generally covers the same pertinent information: The patient’s presenting complaint, assessment findings, medical history, diagnosis, and treatment plan. 

Here’s an example ER Dr. note to illustrate how a well-designed template can streamline documentation processes in emergency medicine settings.

Chief Complaint and Triage Information

The first section of an emergency room doctor's note captures the patient's reason for seeking emergency care and initial assessment information. The assessing clinician may gather this initial information from the patient, family & friends, EMS report, triage staff, medical chart, and referral source. 

Notes should be objective and fact-based as far as possible. However, it’s ok to include some subjective information in the opening section of an ER Dr. note, as self-reported symptoms and clinical hypotheses may help form the basis for subsequent assessment and investigation.

Example note

Chief Complaint: Severe chest pain radiating to left arm x 2 hours

Triage Time: Attended via ambulance at 15:30

Vital Signs: BP 165/95, HR 92, RR 22, Temp 98.6°F, SpO2 97% on RA

Triage Acuity: ESI Level 2

History of Present Illness (HPI)

HPI expands on the initial description of the chief complaint, providing a detailed narrative of the problem and symptoms, including onset, duration, aggravating and alleviating factors, and any other relevant context. 

Example note

54-year-old male with history of hypertension presents with sudden onset crushing chest pain that began while mowing the lawn approximately 2 hours prior to arrival. Patient describes pain as 8/10 in severity, substernal, radiating to left arm and jaw, associated with diaphoresis and shortness of breath. Pain unrelieved by rest. Denies prior similar episodes. Last cardiac evaluation was 3 years ago with normal stress test.

Medical History and Medications

This section of an emergency room doctor’s note lists the patient's pre-existing conditions, medications, allergies, and other relevant background information that may influence clinical decision-making or management options.

Example note

Past Medical History: Hypertension, Type 2 Diabetes, Hyperlipidemia

Surgical History: Appendectomy (2005)

Medications: Lisinopril 20mg daily, Metformin 500mg BID, Atorvastatin 40mg daily

Allergies: Shellfish (rash and diarrhea)

Social History: Current smoker (1 PPD x 30 years), occasional alcohol use

Family History: Father with MI at age 59, mother with hypertension

Physical Examination

Most emergency room documentation templates include a dedicated section for a full physical examination or review of systems. Here, the emergency physician documents findings for each bodily area, often focusing on the systems most relevant to the presenting complaint.

Example note

General: Alert, appears uncomfortable, diaphoretic

Vital Signs: BP 162/90, HR 94, RR 20, Temp 98.4°F, SpO2 96% on RA

HEENT: Normocephalic, atraumatic. Pupils equal and reactive. Oropharynx clear

Neck: Supple, no JVD, no carotid bruits

Cardiovascular: Regular rate and rhythm, S1/S2 normal, no murmurs/rubs/gallops

Respiratory: Clear to auscultation bilaterally, no wheezes/rales/rhonchi

Abdomen: Soft, non-tender, non-distended, normal bowel sounds

Extremities: No edema, pulses 2+ and equal bilaterally

Neurological: Alert and oriented x3, cranial nerves II-XII intact, normal strength and sensation in all extremities

Diagnostic Studies

To aid in assessment and decision-making, all diagnostic studies and tests performed during the emergency department visit should be organized into one section of the ER doctor’s note. This collection of information provides objective data that supports the clinician’s diagnosis and treatment plan.

Example note

ECG: NSR with 1mm ST elevation in leads V2-V4

Chest X-ray: No acute cardiopulmonary process, normal cardiac silhouette

Laboratory:

- Troponin I: 0.12 ng/mL (elevated)

- CK-MB: Pending

- CBC: WBC 9.2, Hgb 14.1, Plt 210

- BMP: Na 138, K 4.2, Cl 101, CO2 24, BUN 18, Cr 1.0, Glucose 142

- PT/INR: 12.1/1.0

Assessment and Plan

The assessment and plan section of an ER Dr. note represents the synthesis of all collected information. It focuses on the physician's clinical impression and the recommended treatment or management strategy.

For simple presentations, the assessment and plan section may be quite brief. However, complex or undifferentiated cases may require additional details, including differential diagnoses, further investigations, and expanded context to support the clinician’s decisions and recommendations.

Example note

Assessment:

1. Acute coronary syndrome, likely STEMI based on clinical presentation and ECG findings

2. Hypertension, poorly controlled

3. Type 2 Diabetes

Plan:

1. Activate cardiac catheterization lab for emergent PCI

2. Administer:

   - Aspirin 325mg PO (already given)

   - Clopidogrel 600mg loading dose

   - Heparin 5000 units IV bolus

3. Continue cardiac monitoring

4. Cardiology consultation completed, Dr. Wilson accepting patient

5. Admission to CCU

Disposition and Follow-up

This final section of an emergency room doctor's note describes the patient's discharge or transfer destination, provides instructions for transfer of care, and details any plans for follow-up. For patients returning home or to a community care facility, it may be appropriate for the clinician to provide return precautions, detailing circumstances under which the patient should return to hospital.

Where appropriate, this section may be replaced by or duplicated in a discharge summary. Other documents, such as a nursing care plan, mental health assessment, or medical referral letter may also be referenced or included with disposition and follow-up notes. 

Example note

Disposition: Admit to CCU under Cardiology service (Dr. Wilson)

Condition at Disposition: Stable but requires ongoing cardiac monitoring and intervention

Follow-up: Cardiology follow-up to be arranged prior to discharge

Patient/Family Education: Discussed diagnosis, treatment plan, and reason for admission with patient and wife

Emergency Room Doctor’s Note Template Example

Most clinicians find that a well-designed template reduces the time and stress involved in emergency room charting. However, in a busy emergency medicine setting, practitioners still frequently struggle to balance administrative duties with clinical care delivery.  

Write Accurate ER Notes Faster with Heidi

With its advanced ambient AI and purpose-built templates, Heidi’s AI medical scribe significantly reduces the time and stress of writing emergency room doctor’s notes. Here’s how to use Heidi to write a perfectly formatted ER doctor’s note within seconds of finishing a clinical encounter:

• Step 1 - Press ‘Start transcribing’ and Heidi processes everything that's said during the session.
• Step 2 - Upload background information and investigation results to the Context tab (files and images of any format may be added).
• Step 3 - Press ‘Stop’ and Heidi automatically generates an editable ER doctor’s note ready to be reviewed and placed on the patient’s medical record.
• Step 4 - Ask Heidi to produce any additional required, such as referral letters, patient handovers, discharge summaries, and medical reports.  

Heidi is trusted by clinicians of all backgrounds, assisting with over one million patient encounters each week. A true global solution, Heidi meets or exceeds privacy and security standards worldwide, including HIPAA, PIPEDA, GDPR, and APP. Heidi is the AI scribe of choice for clinicians who want to spend less time on notes while delivering warmer, more attentive care.

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Free Emergency Room Doctor’s Note Templates

Emergency Medicine Assessment Template

This ER doctor’s note template is designed for emergency medicine specialists to document initial patient assessments. It includes sections for chief complaints, past medical history, medications, allergies, history of present illness, review of systems, physical examination, investigations, assessment/plan, and follow-up recommendations.

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Emergency Room Doctor’s Follow-Up Note

Created specifically for follow-up assessments, this emergency room note template helps clinicians summarize the reason for the patient’s visit, followed by reassessment findings and an updated plan (including treatments, follow-up appointments, and patient education). It uses a more concise format than a full assessment to aid in efficient documentation.

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Emergency Room Discharge Note

Discharge instructions are crucial for ensuring patients understand their diagnosis, treatment, and follow-up care after an emergency visit. This ER  discharge note template helps emergency medicine specialists to provide clear and comprehensive discharge instructions, enhancing patient safety and compliance. 

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Emergency Room Doctor’s Note FAQs

Can I get a doctor's note from the emergency room?

Yes, emergency departments will generally provide a doctor’s note, medical certificate, or after visit summary upon request. These documents may include a summary of your diagnosis, treatment received, and any temporary work restrictions. It’s best to ask for a doctor’s note before leaving the emergency room, but you can also contact the hospital after discharge if required.

Is it ok to use different templates for ER doctors notes?

Absolutely. Different templates cater to varying clinical scenarios and practitioner preferences. Some of the formats that may be used for an ER doctor’s note include an SBAR template for handing over to another team, trauma assessment for injury cases, and mental state examination (MSE) for psychiatric presentations.    

How do I create my own emergency room doctor’s note template?

Creating your own emergency room doctor’s note template in Heidi is easy. You can: a) Modify an existing template from the Community to suit your needs; b) Provide a sample ER Dr. note, and Heidi will turn it into a template; c) Build a template from scratch using our template editor. Full instructions are available in the Help Centre article on creating templates.