Emergency Medicine Specialist Template

ED note

A professional Emergency Medicine Specialist template for healthcare professionals.

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Specialty

Emergency Medicine Specialist

Used

127 times

Type

Note

Last edited

9/20/2024

Created by

Hazim Faragallah

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About this template

This ED note template is designed for Emergency Medicine Specialists to document patient encounters in the emergency department. It includes sections for the reason for presentation, history of presenting illness, past medical history, medications, allergies, and more. The template also covers management en route with QAS, examination findings, investigations, assessment, and management in the emergency department. This comprehensive template ensures that all critical information is captured efficiently, aiding in accurate diagnosis and treatment planning. Ideal for emergency medicine documentation, this template streamlines the process for clinicians using Heidi, the AI medical scribe.

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REASON FOR PRESENTATION: - Chest pain and shortness of breath HISTORY OF PRESENTING ILLNESS: - Onset of symptoms: 2 hours ago - Description of symptoms: Severe, crushing chest pain radiating to the left arm - Additional relevant symptoms: Nausea and sweating - Possible triggers or exposures: Physical exertion - Relevant background information: History of hypertension REVIEW OF SYSTEMS: - Cardiovascular: No palpitations, no previous episodes of chest pain - Respiratory: No cough, no wheezing MANAGEMENT EN ROUTE WITH QAS: - Details of treatment provided by QAS Ambulance enroute to Hospital: Oxygen therapy and aspirin administered - Outcome of treatment provided by QAS Ambulance enroute to Hospital: Partial relief of symptoms PAST MEDICAL HISTORY: - Hypertension - Appendectomy in 2010 MEDICATIONS: - Lisinopril 10 mg daily ALLERGIES: - Penicillin SOCIAL HISTORY: - Lives alone, works as a construction worker DRUG, TOBACCO, ALCOHOL HISTORY: - Alcohol: Social drinker - Tobacco: Smokes 10 cigarettes per day FAMILY HISTORY: - Father had a myocardial infarction at age 55 IMMUNISATION HISTORY: - Up to date with vaccinations EXAMINATION: Vitals: - Blood pressure: 150/90 mmHg - Heart rate: 95 beats/minute - Oxygen saturation: 94% on room air General: Alert, in mild distress CVS: Regular heart sounds, no murmurs Resp: Clear breath sounds bilaterally Abdo: Soft, non-tender Neuro: No focal neurological deficits INVESTIGATIONS: Bloods: - Troponin: Elevated Radiology: - Chest X-ray: No acute findings ASSESSMENT: - Primary diagnosis: Acute coronary syndrome - Secondary diagnoses or issues: Hypertension MANAGEMENT IN EMERGENCY: - Details of treatment provided in Emergency Department today: Administered nitroglycerin and morphine - Outcome of treatment provided in Emergency Department today: Significant relief of chest pain PLAN: - Admission plan and team assignment: Admit to Cardiology - Dietary instructions: Cardiac diet - Fluid management plan: IV fluids as needed - Medication orders: Continue aspirin, start beta-blocker - Consults and referrals: Cardiology consult - Monitoring instructions: Continuous cardiac monitoring - Disposition plan: Transfer to Cardiology unit