ED Encounter Note (Treat-and-Release)

(For any missing patient identifiers or authorship details, insert [REQUIRED]. Omit optional/conditional sections entirely if not applicable. Keep documentation concise and focused on decision-making.)

Patient: [Patient name] | [Date of birth] | [Age] | [Sex]

MRN/Encounter: [Medical record number] | [Encounter number]

Facility: [Site name]

ED Arrival: [Date and time of ED arrival]

Mode of Arrival: [walk-in / EMS / transfer / police custody] (If EMS, include relevant pre-arrival care and patient response.)

Triage Acuity: [ESI level or local equivalent]

Primary Language: [Language]; Interpreter: [none / in-person / phone / video]

Rendering Clinician: [Name, credentials]

Note Date/Time: [Date and time note created]

Chief Complaint

[Chief complaint] (Use direct patient quote when it clarifies the complaint. If clinician assessment differs from triage chief complaint, note both.)

History of Present Illness

[HPI narrative] (Begin with the chief complaint and baseline before symptom onset. Include onset, duration, course, severity, context, provoking and palliating factors, associated symptoms, and integrated pertinent negatives affecting the differential. Include pre-ED care such as EMS treatments, urgent care evaluations, or home medications taken for this episode with response.)

[Risk context if relevant: pregnancy possibility/LMP, anticoagulation status, immunocompromise, substance use, recent procedures, travel, sick contacts]

[History source and limitations] (Identify non-patient historians and their contributions. If the patient cannot provide history, document why and which alternative sources were used. Do not document denials for history not actually obtained.)

Review of Systems

(Include only if a problem-focused ROS adds decision-making value beyond the HPI. Omit this entire section if a broad ROS was not performed.)

• [System]: [Pertinent positives/negatives relevant to the presenting problem and high-risk exclusions]

Relevant Background

Past Medical History: [High-impact conditions affecting risk or management] (Use relevance tags as needed, e.g., "AF on apixaban (bleeding risk)".)

Past Surgical History: [Only surgeries/procedures relevant to current complaint]

Medications: [Pertinent home medications] (Note if full list reviewed in chart; do not import entire lists.)

Allergies: [Allergen(s) with reaction type / NKDA / Allergies unknown with reason]

Social History: [SDOH factors that change management] (Include only if it affects today's plan: housing, substance use, caregiver support, safety concerns.)

Vital Signs

• Triage: [Time] — [Temp], [HR], [BP], [RR], [SpO2] [room air / supplemental O2 with device and flow], Pain [score]
• Most recent/discharge: [Time] — [Temp], [HR], [BP], [RR], [SpO2] [room air / supplemental O2 with device and flow], Pain [score]
• Weight: [kg] (Include if weight-based dosing used.)

(If vitals unobtainable or refused, document reason.)

Physical Examination

General: [Appearance, work of breathing, perfusion status]

[Focused system-based examination findings] (Document pertinent positives and negatives tied to the complaint. Include mental status or capacity assessment when relevant to high-risk decisions. Note when exam is limited by pain, agitation, or other factors. Do not list normal findings for systems not examined.)

Diagnostics and Results

(Include only if testing was performed. Summarize key abnormal findings and decision-driving normal results with brief interpretation. Do not list pending tests here.)

• Laboratory: [Key results with interpretation relevant to today's problem]
• Imaging: [Study type] — [Independent interpretation and/or radiology read]; [Comparison to prior if relevant]
• ECG: [Rate, rhythm, intervals, ischemia/arrhythmia assessment]
• Point-of-care ultrasound: [Indication, views, key findings, interpretation]
• External/prior results reviewed: [What was reviewed and relevance]

ED Course and Re-evaluations

(Chronological account of care. Use actual timestamps when provided; otherwise use relative timing such as "after CT results".)

• [Time] — [Initial assessment and key concerns]
• [Time] — [Interventions/medications/fluids with doses; patient response including symptom or pain score change]
• [Time] — [Results returned and impact on decisions]
• [Time] — [Re-examination findings, clinical trajectory, serial vitals]
• [Time] — [Consultation: service, question, recommendations, impact on plan] (if applicable)
• [Time] — [Shared decision-making, refusal of care with capacity assessment and risk mitigation] (if applicable)
• [Time] — [Disposition decision and rationale]

Medical Decision Making

(Organize by problem in decreasing acuity. Tailor reasoning to this specific encounter; avoid generic statements.)

[Problem 1]: [Working diagnosis]

• Differential: [Focused differential including pertinent "can't miss" diagnoses]
• Data considered: [History source(s), prior records reviewed, key labs/imaging/ECG interpretations, consultant input]
• Clinical reasoning: [Why certain diagnoses are more/less likely; why specific tests were ordered or deferred]
• Management: [Treatments given, prescriptions, specific follow-up plan]
• Risk and disposition rationale: [Condition-specific risk assessment; why outpatient management is appropriate]

(Include if applicable: clinical decision tool with inputs and risk category; social/access factors affecting plan; patient refusal with capacity, risks discussed, and alternatives offered.)

[Problem 2]: [Working diagnosis]

(Repeat structure for additional problems as needed.)

Procedures

(Include only if procedures were performed; otherwise omit this section entirely.)

[Procedure name]

• Indication: [Indication]
• Consent: [verbal / written / emergent without consent] from [patient / surrogate]
• Pre-procedure verification/time-out: [completed / not applicable]
• Anesthesia/analgesia: [Agent(s), dose(s), route]
• Technique: [Key steps; guidance used if any]
• Findings: [Findings]
• Complications: [none / description]
• Post-procedure status: [Immediate outcome]
• Aftercare: [Wound care, suture removal timing, restrictions]

Procedural Sedation

(Include only if procedural sedation was performed.)

• Pre-sedation assessment: [ASA class, airway, fasting status, risk/benefit discussion]
• Medications: [Agents with doses, routes, times]
• Monitoring/personnel: [Monitoring used; personnel present]
• Course/adverse events: [Events and management, or "none"]
• Recovery: [Return to baseline, discharge readiness criteria met]

Consultations

(Include only if consultations occurred; otherwise omit this section entirely.)

• Service/Consultant: [Name/service]; Question: [Specific question]; Recommendations: [Key points]; Impact: [How recommendations affected management/disposition]
• Non-physician resources: [Case management / social work / poison control] — [Recommendations and actions] (if applicable)

Disposition

Diagnoses: [Final ED impression(s)]

Condition at Discharge: [improved / stable / at baseline] — [Supporting findings: symptom trend, vitals, oral intake, ambulation, neuro status as relevant]

Discharge Medications: [New prescriptions with dosing and key counseling points]

Follow-up: [Specific clinician/service] within [timeframe]; [Escalation plan if follow-up cannot be obtained]

Return Precautions: [Diagnosis-specific red flags in patient-facing language] (Connect to any remaining diagnostic uncertainty.)

Pending Results: [What is pending, how patient will be contacted, actions to take if symptoms change before results return]

Restrictions/Safety Counseling: [Activity/work restrictions, safety counseling] (if applicable)

(If patient declined written instructions or left before instruction completion, document what was provided and what could not be completed.)

Signature

[Electronic signature of rendering clinician with credentials, date, and time]

[Scribe or AI transcription attestation per local policy] (if applicable)