Emergency Medicine Custom Template

[Patient age and sex] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Chief Complaint: [Presenting complaint including primary symptom and affected area] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) History of Present Illness: [Detailed narrative of symptoms and relevant history including pertinent negatives, risk factors, and exposure] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Previous occurrences of current symptoms or issues including recent visits, assessments, and hospital admissions in the last year] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Related visits, investigations, management, and any diagnoses] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Medications taken and the patient's response to them] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Associated symptoms accompanying the presenting complaint] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Other relevant history pertaining to the presenting complaint] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Past Medical History (not comprehensive): - [List of past medical conditions] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Family history including relevant hereditary or familial conditions] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Social history including smoking, alcohol consumption, and drug use habits] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Medications (not comprehensive): - [Current medications including name, dose, and frequency] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Allergies: - [Known allergies and associated reactions] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Review of Systems: [Summary of pertinent positive and negative findings from a review of systems] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points or in a paragraph as appropriate.) Physical Examination: - General Appearance: [Brief description of general appearance and level of distress] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Vital Signs: [Temperature, blood pressure, heart rate, respiratory rate, oxygen saturation, and any other vital signs] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - HEENT: [Findings related to head, eyes, ears, nose, and throat] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Respiratory: [Findings related to the respiratory system including air entry, crackles, or wheeze] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Cardiac: [Findings related to the cardiovascular system including heart sounds and murmurs] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Abdominal: [Findings from abdominal examination including palpation and tenderness] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Skin: [Findings related to skin including rashes and other dermatological features] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Other: [Any other physical examination findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Side Room Investigations: - HGT: [Result of HGT blood glucose test] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Haemoglobin: [Result of haemoglobin test] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Assessment: - [Primary diagnosis] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis.) - Differential Diagnoses: 1. [First differential diagnosis] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis.) 2. [Second differential diagnosis] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis.) 3. [Third differential diagnosis] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis.) Plan: - [Overall plan for further assessment, diagnosis, and management in the emergency department and post-discharge] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Recommended medications and dosage] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [General patient care advice] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Danger signs that would prompt a return to the emergency department] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Follow-up recommendations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Investigations: - [Results of basic blood work] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Results of any imaging performed] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Electrocardiogram findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Final/Working Diagnosis: - [Whether this represents a final or working diagnosis] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis.) - [Primary diagnosis with supporting rationale] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis.)