ER Note

[Age of patient] [patient gender] presenting with [main complaint] PMH [Insert patient medical past history] [Insert patient surgical past history] [Insert pertinent family history if mentionned] Habits (include in PMH section) [Insert smoking history if mentionned] [Insert drugs if mentionned] [Insert alcohol if mentionned] Meds cf list [Insert patient medication] [Insert patient natural product if mentionned] HPI [Insert description about primary complaint localisation of pain, irradiation of pain, type of pain, level on 10 of pain, anything that improves or worsens the pain, or description of events or symptom in patients word] (write all these findings with à comma in between on one line of bullet point) [Insert related symptoms to primary complaint depending on instructions for each complaint] Cardio (if complaint is chest pain, shortness of breath, palpitation or syncope or loss of consciousness mention in symptoms related to present complaint) [Insert if patient has chest pain, shortness of breath, orthopnea, paroxysme nocturnal dyspnea, leg swelling, palpitations, syncope, symptoms prior to the syncope/loosing consciousness, symptoms after loosing consciousness/syncope] (Insert with comma between symptoms on same line for all cardio symptoms) Respiratory [Insert if patient has shortness of breath, cough, expectoration, color of expectoration, increase from usual amount of expectoration, coughing more fréquently then usual, change in color of expectorations, urti symptoms, rhinorrhea, hemoptysis] [If patient is speaking mention symptoms that are Pulmonary embolism risk factors here, past history of dvt or PE, calf symptoms, hemoptysis, ocp or hormone therapy, recent immobilisation, recent surgery or cast] (If say no PE risk factors in transcription please write no phx of dvt or PE, no calf symptoms, no recent immobilisation, no hemoptysis, no ocp or hormone use) (mention in history of present illness if patient is having chest pain, shortness of breath or syncope) Abdominal: (if complaint is abdominal pain, pelvic pain, flank pain, chest pain include in symptoms related to présent illness) [include nausea, vomiting, diarrhea, hématemesis, melena, Bright red flood per rectum, constipation, abdominal pain, rectal pain, alcohol consumption, consumption of anti inflammatories, urinary symptoms : frequency, hematuria, dysuria, nycturia] [if mention no urinary symptoms when using transcription please write no hématurie, no dysuria, no frequency] (put in one paragraph with commas) Gyne/Gu (if complaint is urinary symptoms, flank or pelvic pain include in history of present illness) [urinary symptoms : frequency, hematuria, dysuria, nycturia, flank pain, pelvic pain, abdominal pain, change in vaginal discharge amount or color, new sexual partner, stable sexual partner, other sexual partner if has stable or partner has another partner, previous diagnosis of std, last tested for std, rectal pain, anal intercourse, oral intercourse receptive or giving, vaginal intercourse, sexual abuse, abnormal vaginal bleeding, last mentrual period, possibility of being pregnant, sexually active] (put in one paragraph with commas) (If say no urinary symptoms please write in parenthesis: no dysuria, no frequency, no hematuria) Neurological symptoms (if complaint is neurological symptom, diziness, loss of vision, headache, syncope, vertigo, aphasia, weakness, confusion, please incluse in history of present illness) [headache, head trauma, aphasia, ataxia, dysarthria, dysphagea, dysphonia, weakness in a limb, parestesias or loss of sensation in a limb, loss of vision, double vision, confusion, neck pain, chiropracter neck manipulation, been in a ride at an amusement park] (if I mention no neurological symptoms when transcribing please write : no aphasia, no ataxia, no dysarthria, no dysphagea, no dysphonia, no vision change (diplopia or loss vision), no peripheral neuro sx (sensory or motor) in parenthesis) Constitutional symptoms (mention in history or present illness) [fever, chills, myalgia, arthralgia, unexplained fevers, unexplained weight loss, swollen lymph node, sick contact] [if mention no B symptoms in rédaction write no unexplained weight loss of fever] Eyes: [Symptoms like Eye pain, Swelling, Redness, Foreign body sensation, Discharge, Vision changes] (include in HPI if main complaint is vision loss, eye foreign body, eye trauma, floater or flashing lights in vision, red eye) Ears, Nose, Mouth, Throat: [Symptoms like Hearing changes, Ear pain, Nasal congestion, Sinus pain, Hoarseness, Sore throat, Rhinorrhea, Swallowing difficulty] (mention in HPI if main compaint is hearing loss, thorat pain, ear pain, dysphagea, change in voice, URTI symptoms) (For review of systems that are not included in hpi please include in a separate paragraph on same line separated by commas) PE (if say normal exam : write the exam mentioned in plain text below HN, heart, lungs, adbo for all patients unless there are added description for physical exam) [write general appearance] [vital signs] (if mention normal or stable vitals write VSS) H/N N Heart Ns1s2, (write no murmurs if complaint is syncope or chest pain) Lungs: clear GEAB Abdo: soft (if complaint if abdominal, flank or pelvic pain write : no guarding, no rebound, no peritoneal) I/P [main diagnosis and clinical reasoning] (write in one line with commas) [other diagnosis with clinical reasoning] (write in one line with commas) [orders, medications, imagining] (in one line with commas) Reassessment [date and time mentionned on transcribing] [insert clinical assessment of patient's symptoms] Exam [insert changes or updates in physical exam] (omit if not explicitely mentionned) I/P [insert changes and updates in previously described plan] (do not recopy previous plan or modifiy initial plan)