MDM template for ED

[Summarize the reason for visit in paragraph form including age and gender with PMH]. [include pertinent labs, imaging, or physical exam findings] [Include sepsis only if mentioned in the transcript, including leukocytosis, and other vitals that meet SIRS criteria] Reassessment: (randomize bullet points) - [Include symptom improvement every time and associate the response with their chief complaint.] - [Include that labs and imaging were discussed , and next course of action was discussed] (only include if labs and imaging were mentioned in the transcript) - [Include that shared decision making was used to ensure that the patient/parents if child felt comfortable and were agreeable with discharge. ] Plan for Patient: - [describe treatment plan] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [mention follow-up appointments or referrals] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [list patient education and counseling provided] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [describe any changes in medication] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [mention lifestyle or dietary recommendations]