About this template
The MDM template for ED is designed for Emergency Medicine Specialists to efficiently document patient encounters in the emergency department. This template helps clinicians summarize the reason for the visit, reassessment findings, and the plan for the patient, including treatment plans, follow-up appointments, and patient education. It ensures comprehensive documentation of critical information, facilitating effective communication and decision-making. This template is particularly useful for capturing the dynamic nature of emergency care, where rapid assessments and shared decision-making are crucial. Ideal for emergency medicine documentation, it enhances the accuracy and completeness of medical records.
Preview template
Patient is a 45-year-old male who presented to the emergency department with complaints of severe abdominal pain and nausea. His past medical history includes hypertension and type 2 diabetes. On examination, the patient was found to have tenderness in the right lower quadrant. Laboratory tests revealed leukocytosis, and a CT scan of the abdomen showed signs consistent with appendicitis.
Reassessment:
- The patient's abdominal pain has improved following administration of analgesics.
- Labs and imaging were discussed with the patient, and the next course of action was agreed upon.
- Shared decision-making was used to ensure the patient felt comfortable and agreeable with the discharge plan.
Plan for Patient:
- The patient will undergo an appendectomy later today.
- Follow-up appointment with the surgeon is scheduled for 7 days post-operation.
- Patient was educated on post-operative care and signs of infection to watch for.
- No changes in medication were made at this time.
- Advised to maintain a light diet post-surgery and increase fluid intake.
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