Acute Care ED Encounter Note (Admit/Transfer)

Date/Time: [Encounter date and time]
Author: [Clinician name and role]
Arrival: [Arrival date/time]; [EMS / walk-in / transfer-in] (Include sending facility if transfer-in.)
Triage Acuity: [ESI level]
Historian: [Source(s) of history and reliability] (Note limitations such as altered mental status, intubation, or acuity if applicable.)
Interpreter: [Language and modality] (Omit line if not applicable.)

Chief Complaint

"[Chief complaint]" ([per patient / per EMS / per family / per caregiver])

History of Present Illness

[One-liner: age, key relevant history, and presenting complaint. Symptom timeline and onset, severity, location and quality, aggravating/relieving factors, associated symptoms, and key pertinent negatives tied to high-risk diagnoses. Relevant context including exposures, recent procedures, anticoagulant use, pregnancy status, baseline function, recent admissions. Prehospital interventions and response if EMS arrival. Patient goals or preferences if they influenced care.] (Use direct quotes only for high-stakes statements such as refusal of care, suicidal ideation, or goals of care. For essential missing information that would alter management, document: "Unable to obtain due to [reason]" and sources attempted.)

Pertinent History

• PMH: [Conditions affecting current risk stratification]
• Medications: [High-impact medications only: anticoagulants, insulin, immunosuppressants, opioids] (Reference full list location if elsewhere.)
• Allergies: [Allergen and reaction type] (Note if reaction unknown.)
• Social: [Substance use, living situation, supports relevant to disposition]
• Code Status: [Status, decision maker, and source] (Include only if relevant to care; if unknown and patient lacks capacity, note interim plan.)

Vital Signs

Initial: T [temp], HR [rate], BP [pressure], RR [rate], SpO2 [value] [on room air / on O2 via NC at L/min / HFNC FiO2/flow / NIPPV settings / ventilator mode and settings], Pain [score]
Most Recent: T [temp], HR [rate], BP [pressure], RR [rate], SpO2 [value] [oxygen delivery method], Pain [score]
(For unstable patients, include key trend data. Include ventilator parameters if intubated.)

Physical Exam

• General: [Appearance and distress level]
• Mental Status: [Alertness, orientation, GCS if altered]
• Airway/Respiratory: [Airway patency, work of breathing, breath sounds, response to therapy]
• Cardiovascular: [Skin color and temperature, capillary refill, pulses, edema, JVP if relevant]
• Focused Exam: [Targeted findings for chief complaint including key negatives supporting risk assessment]
• Other Systems: [Additional examined systems with decision-relevant findings] (Include only if relevant.)

Diagnostic Results

• Labs: [Critical abnormalities and values driving disposition] (Include only decision-relevant data.)
• Imaging: [Modality and impression summary with key negatives relevant to working diagnosis]
• ECG: [Rate, rhythm, intervals, ischemic changes, clinician interpretation] (Include if it influenced care.)
• POCUS: [Indication, key findings, impact on management] (Include only if performed.)

ED Course

(Time-stamped chronological bullets capturing presentation → evaluation → stabilization → reassessments → disposition. Summarize only clinically meaningful interventions and responses.)

• [HH:MM] – [Initial assessment: brief status and immediate concerns]
• [HH:MM] – [Key intervention and response]
• [HH:MM] – [Reassessment: vitals, exam changes, response to therapy]
• [HH:MM] – [Critical result and action taken]
• [HH:MM] – [Consultant contacted, recommendations, acceptance]
• [HH:MM] – [Deterioration and rescue actions] (Include only if applicable.)
• [HH:MM] – [Disposition decision and rationale]

Assessment and Medical Decision Making

[Summary statement: illness severity, working diagnosis, and why admission or transfer is required]

Problems: (List in descending severity.)

• [Problem 1]: [Working diagnosis with brief rationale] (Use "suspected/likely/cannot exclude" as appropriate.)
• [Problem 2]: [Brief rationale]
• [Additional problems as applicable]

Differential:

• [Leading diagnosis] – [Why favored]
• [High-risk alternative 1] – [Supporting or refuting evidence; contingency if still possible]
• [High-risk alternative 2] – [Supporting or refuting evidence; contingency if still possible]

Data Reviewed:

• [Tests ordered and key results influencing decisions]
• [External records reviewed and relevance]
• [Independent interpretations: ECG, imaging, POCUS]
• [Consultant discussions: service, recommendations, acceptance]

Risk and Level of Care: [Rationale for ICU vs stepdown vs telemetry vs floor; high-risk medications initiated; need for invasive monitoring; barriers to completing workup prior to disposition]

Disposition

Disposition: [Admit to service/level / Transfer to facility]

For Admission

• Admitting Service: [Service/team and accepting clinician]
• Level of Care: [ICU / stepdown / telemetry / floor / observation] – [Rationale]
• Condition at Handoff: [stable / guarded / critical] – [Brief clinical context]
• ED Boarding Plan: [Monitoring frequency, escalation triggers, interim therapies] (Include if boarding.)
• Pending Results: [Pending labs, cultures, imaging reads] – [Who will follow up]

For Transfer

• Reason for Transfer: [Specific capability required: specialty, procedure, ICU, center designation]
• Receiving Facility: [Facility name], [Accepting clinician/service], [Acceptance time]
• Patient Condition: [Clinical status at decision and stabilization performed]
• Risk-Benefit Discussion: [Benefits of transfer] vs [Risks specific to this patient and transport]
• Consent: [Patient/surrogate consent obtained / Physician-initiated transfer with certification that benefits outweigh risks]
• Transport: [Ground / air], [BLS / ALS / critical care], [Required equipment and therapies en route]
• Records Sent: [Documents transmitted and what remains pending]
• Handoff: [Communication method with receiving team; confirmation of questions answered]
• Pending Results: [Pending items] – [Responsibility for follow-up]

(If patient left AMA, eloped, or died in ED: document capacity assessment, informed discussion, and safety planning as applicable.)

Procedures

(Include this section only if procedures were performed.)

• Procedure: [Name] | Indication: [Indication] | Consent: [obtained / emergency exception] | Technique: [Key details] | Confirmation: [Method] | Complications: [none / describe] | Response: [Outcome]

Critical Care

(Include this section only when critical care services were provided and billed.)

Critical Care Time: [Total minutes] (exclusive of separately billable procedures). Patient was critically ill with [organ system failure or imminent risk of deterioration], requiring [high-complexity interventions performed]. (If family discussion time included, document why patient could not participate and why discussion was necessary for treatment decisions.)