ED Notes 1

Chief Complaint

[Presenting problem + duration in one concise sentence]

Past Medical History

• [Relevant medical history]
• [Past surgical history]
• [Family history]
• Social history: [Smoking/alcohol/drugs/occupation/living situation—only if stated]

Medications

• [Current medications + source of information]

Allergies

• [Documented allergies + reactions]

History of Present Illness (HPI)

[Provide a structured, chronological, clinically focused narrative including all explicitly mentioned features.]

Review of Systems

• Constitutional: […]
• ENT: […]
• Eyes: […]
• CVS: […]
• Respiratory: […]
• Gastrointestinal: […]
• Genitourinary: […]
• Musculoskeletal: […]
• Skin: […]
• Neurological: […]
• Psychiatric: […]
• Endocrine: […]
• Haematologic/Immunologic: […]

Physical Examination

• General: [Appearance, distress level]
• Vital Signs: [Record all explicitly provided vitals]
• Airway/Breathing/Circulation: [If mentioned]
• Respiratory exam: […]
• Cardiovascular exam: […]
• Abdominal exam: […]
• Neurological exam: […]
• Skin: […]
• Other systems: […]

Investigations

• Blood tests: […]
• Imaging: […]
• ECG: […]
• Other tests: […]

Assessment & Plan

• Working diagnosis: [FRCEM style emphasis]
• Differential diagnoses: [Explicit only]
• Risk stratification or scoring tools: [If stated]
• Management plan in ED:
  • Tests ordered
  • Treatments given
  • Observations required
• Medications: [type + dose only if stated]
• Safety-netting advice: [Explicit only]
• Disposition: [Discharge, admission, referral—only as stated]

GP/Primary Care Follow-up

[List ONLY items the ED clinician specifically requests for GP follow-up]

Final vs Working Diagnosis

• [State whether the diagnosis is final or working as per the transcript]
• [Primary diagnosis only]