Triage 2-4 ED template

Consent to use of AI scribe obtained Presenting Complaint: [document the patient's primary reason for seeking emergency medical attention, including the chief complaint and its duration] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) History of Presenting Complaint: [detail the chronological development of the presenting complaint, including onset, character, location, radiation, associated symptoms, timing, exacerbating and relieving factors, and severity] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Systems Review: [document a comprehensive review of all major body systems to identify any other relevant symptoms or concerns not directly related to the presenting complaint, including general, cardiovascular, respiratory, gastrointestinal, genitourinary, neurological, musculoskeletal, and dermatological systems] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Past Medical History: [record all significant past medical conditions, chronic diseases, previous hospitalizations, and relevant medical treatments] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Past Surgical History Medication History: [list all current and recent medications, including prescription drugs, over-the-counter medications, herbal supplements, and recreational drugs, specifying dosage, frequency, and route] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Allergies: [document all known allergies to medications, food, or environmental factors, including the type of reaction experienced] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Social History: [describe relevant social factors such as living situation, occupation, smoking status, alcohol consumption, illicit drug use, and social support system, and job] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Observations: [record vital signs including temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation, along with any other relevant objective measurements] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Physical Examination: [document findings from a focused physical examination relevant to the presenting complaint and systems review, including general appearance, head and neck, cardiovascular, respiratory, abdominal, neurological, and musculoskeletal findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Differential Diagnosis: [list potential diagnoses that could explain the patient's symptoms, ordered by likelihood, along with brief justifications for each] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Likely Diagnosis: [state the most probable diagnosis based on the available clinical information] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Management Plan: [outline the proposed plan for further investigation, treatment, and disposition, including any medications, procedures, consultations, or follow-up arrangements] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) External advice sought: (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. 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.)