Emergency Medicine Specialist Template

Full ED physician note

A professional Emergency Medicine Specialist template for healthcare professionals.

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Specialty

Emergency Medicine Specialist

Used

222 times

Type

Note

Last edited

11/19/2024

Created by

David Rosenstein

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About this template

The Full ED Physician Note template is designed for Emergency Medicine Specialists to document comprehensive patient encounters in the emergency department. This template includes sections for diagnosis, chief complaint, medical history, medications, allergies, and detailed history of present illness. It also covers physical examination findings, investigations, assessment and plan, and follow-up instructions. The template is optimized for use with AI scribe technology, ensuring accurate and efficient documentation. This format is ideal for capturing the critical information needed for patient care and follow-up, making it a valuable tool for emergency physicians.

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Final/Working Diagnosis/ICD-9 Code: Acute appendicitis, 540 Chief Complaint: Severe abdominal pain for 2 days, referred by family physician. Past Medical History (not comprehensive): Hypertension, Type 2 Diabetes. Social history: Lives alone, works as a teacher. Family history: Father had coronary artery disease. Habits: Smokes 10 cigarettes per day, occasional alcohol use. Medications (not comprehensive): Metformin, Lisinopril (information from electronic record). Allergies: NKDA History of Present Illness: The patient presents with severe, sharp abdominal pain localized to the right lower quadrant, worsening over the past 48 hours. No previous episodes of similar pain. Recent visit to family physician who suspected appendicitis. No recent hospital admissions. No nausea or vomiting. No recent changes in bowel habits. No fever. No recent travel or exposure to infectious diseases. No significant response to over-the-counter pain medication. Physical Examination: Patient appears in moderate distress. Vital signs: BP 130/85, HR 95, Temp 37.2°C, RR 18, SpO2 98% on room air. Abdominal examination reveals tenderness in the right lower quadrant with guarding. Investigations: Blood work shows elevated white blood cell count. Abdominal ultrasound indicates an enlarged appendix with surrounding fluid. Assessment/ Plan: I suspect acute appendicitis. Differential diagnosis includes gastroenteritis and ovarian cyst. Plan to admit for surgical consultation and possible appendectomy. Administer IV fluids and analgesics. Advise patient to avoid food and drink. Warn about signs of worsening pain or fever that would require immediate attention. Follow-up with surgical team post-operatively. Possible imaging: CT abdomen/pelvis to confirm appendicitis; severe RLQ pain, elevated WBC. Procedure: Not applicable Course in ER: Not applicable Follow-up for Primary care physician: See assessment/plan Final/Working Diagnosis: Acute appendicitis ICD-9 Code: 540 Dr. John Smith, ER Physician. This note was created using AI/ambient scribe technology. Consent for usage was obtained from patient/guardian.