Emergency Medicine Doctor Template

ED Note

A professional Emergency Medicine Doctor template for healthcare professionals.

About this template

Streamline your Emergency Department documentation with Heidi's "ED Note" template, a comprehensive solution designed for busy emergency medicine doctors. This clinical notes template helps you capture all critical information from patient presentation to discharge planning, ensuring thorough and efficient record-keeping. Perfect for urgent care settings, it guides you through detailing the chief complaint, history of presenting illness, vital ABCDE examination findings, and investigations like blood results and ECGs. Clinicians will find it invaluable for documenting complex cases, from trauma assessments to medical emergencies. The template smartly prompts for relevant medical history, medications, allergies, and social context, enhancing the quality of your medical documentation. Heidi seamlessly populates the note from your dictations, making "ED Note" an indispensable tool for every Emergency Medicine practitioner.

Preview template

72-year-old female Patient arrived via ambulance after a fall at home. Assessed in the Emergency Department. Chief Complaint: Right hip pain and inability to bear weight after a fall. History of Presenting Complaint: * Patient fell approximately 2 hours prior to presentation while walking in her home. * She reports immediately experiencing severe right hip pain and was unable to stand or bear weight. * Pain is described as sharp, constant, and rated 8/10 at rest. * No loss of consciousness, head injury, or altered mental status reported. * No preceding dizziness, chest pain, or palpitations. * Aggravated by any movement of the right leg. * Relieved slightly by lying still. * No fever, chills, or night sweats. * No bowel or bladder incontinence. * No new weakness or sensory deficits. Past Medical History: * Osteoporosis, diagnosed 5 years ago. * Hypertension, well controlled on medication. * Type 2 Diabetes Mellitus, managed with oral agents. * Previous appendectomy (1985). Medications: * Amlodipine 5mg once daily * Metformin 500mg twice daily * Alendronate 70mg once weekly * Calcium Carbonate/Vitamin D 500mg/400IU twice daily Allergies: * Penicillin (rash) * Codeine (nausea) Social History: Patient is a retired teacher, lives alone in a single-story house. Non-smoker, rarely consumes alcohol (socially). No recreational drug use. Receives support from a neighbour for shopping. Family History: Mother had osteoporosis. Father had hypertension and type 2 diabetes. No family history of sudden cardiac death or genetic disorders. Examination: A - Airway: Patent and protected. No stridor or drooling. B - Breathing: Respiratory rate 18 breaths/min. Symmetrical chest expansion. No increased work of breathing. Oxygen saturation 98% on room air. Clear bilateral breath sounds on auscultation. No crepitations or wheezes. C - Circulation: Hr 88 bpm, BP 145/85 mmHg, CRT <2 seconds. Peripheral pulses palpable and strong. No murmurs or gallops on cardiac auscultation. D - Disability: Alert and oriented to person, place, and time (GCS 15). Pupils equal, round, and reactive to light (3mm bilaterally). Motor function intact in upper extremities. Right lower extremity shortened and externally rotated, painful to any movement. Sensation intact bilaterally. E - Exposure: Temperature 36.8. Skin warm and dry, no rashes. Obvious deformity of the right hip with shortening and external rotation. No open wounds or ecchymosis noted at this time. Abdomen soft and non-tender. Investigations: Blood results: * Hb 12.5 g/dL * WBC 8.2 x 10^9/L * Platelets 250 x 10^9/L * Na 138 mmol/L * K 4.0 mmol/L * Creatinine 75 µmol/L * Glucose 6.5 mmol/L * CRP 5 mg/L ECG: Sinus rhythm, normal axis, no acute ischaemic changes. VBG: Not performed. POCUS: Not performed. Impression: Right hip fracture (likely femoral neck fracture) secondary to fall in an elderly patient with osteoporosis. Plan: * Analgesia: IV Paracetamol 1g and IV Morphine 2mg aliquots as needed for pain control. * Immobilisation: Right leg immobilised with a splint. * Imaging: Urgent X-ray right hip and pelvis. CT scan of the hip if X-rays inconclusive or for surgical planning. * Consult Orthopaedics for urgent surgical review. * Admit to orthopaedic ward for further management. * Pre-operative bloods and ECG. * Review bone health and fall prevention strategies post-operatively. Discussion with family - Patient's daughter, Mrs. Sarah Davies, was contacted by phone and updated on her mother's condition. The clinical impression of a fractured hip and the need for urgent orthopaedic review and potential surgery was explained. The risks and benefits of surgery, including anaesthetic risks, were discussed. Mrs. Davies understood the situation and agreed with the proposed plan of care. She will be coming to the hospital to be with her mother. Dr. Alex Carter, Emergency Medicine Consultant

[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.)

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