Emergency Department Encounter Note

Date/Time: [Encounter date and time]

Clinician: [Name and role; scribe involvement if applicable]

Location: [ED site and room/area if relevant]

Arrival: [walk-in / EMS / transfer] | [Triage acuity level]

Chief Complaint

"[Patient's stated reason for visit]"

History of Present Illness

[Cohesive HPI narrative] (Describe onset, duration, timing, severity, location, quality, progression, provoking/relieving factors, associated symptoms, and pertinent negatives that narrow dangerous differentials. Include functional impact and the trigger for today's visit. Integrate targeted ROS inline rather than as a separate section. Attribute historian if not the patient and state limitations to history when present. Include high-risk context if relevant, such as pregnancy status, anticoagulation, immunocompromise, recent procedures, substance use, or trauma mechanism.)

Past History

[Focused prior history relevant to current MDM] (Include only decision-driving items: pertinent past medical/surgical history; current medications with recent changes or adherence issues if relevant; allergies with reaction types; and social determinants of health that affect evaluation or disposition. Briefly state how any SDOH will impact the plan. Omit family history unless it materially changes risk. Omit this section entirely if no past history is relevant to the encounter.)

Physical Examination

Vital Signs: [Initial vitals and clinically meaningful trends] (e.g., initial vs post-intervention values)

[Focused exam findings by relevant systems] (Include mental status and capacity-related observations when refusal, AMA, or high-risk discharge is considered. Document only examination elements that inform diagnosis, risk, or disposition.)

Diagnostics

[Key diagnostic results and interpretation] (Summarize only results that influenced MDM, reassessment, or disposition. Include brief interpretation for abnormal or decision-driving results and pertinent negatives that change risk stratification. For ECG, include time, rhythm, relevant intervals, ischemic changes, and comparison to prior when available. Do not reproduce full lab panels or radiology reports. Omit this section if no diagnostics were obtained.)

Procedures and Interventions

[Therapeutic interventions provided] (Medications, IV fluids, oxygen/ventilation, wound care, splinting/immobilization, other treatments, and the patient's response.)

[Procedure note] (For invasive procedures: include indication; consent or emergency exception; time-out/verification; technique and key findings; complications; patient tolerance; and post-procedure status. Omit this section if no procedures or interventions were performed.)

ED Course and Reassessments

(Chronological timeline capturing key clinical turning points with timestamps or sequence markers. Include reassessments after interventions with patient response, result reviews with clinical interpretation, consultant communications, plan changes or escalation, and clinical basis for disposition readiness. Even brief visits should include at least one reassessment synthesis before disposition.)

• [Time]: [Reassessment after intervention—patient response and current status]
• [Time]: [Result reviewed—clinical interpretation and effect on plan]
• [Time]: [Consultation—service, recommendations, impact on plan]
• [Time]: [Disposition decision—clinical basis and readiness]

Medical Decision Making

Problems and Differential

[Problem 1]: [Key differential diagnoses prioritized by risk] (List "can't miss" conditions and working alternatives. Note supporting and opposing evidence and current status/resolution.)

[Problem 2]: [Key differential and evidence] (Include additional addressed problems only as relevant.)

Data Reviewed

[Data reviewed and interpreted] (Briefly list key labs, imaging, ECG, prior records accessed, independent historian used, independent interpretation of images/traces, and clinical discussions with consultants or specialists.)

Risk and Management

[Risk assessment and management decisions] (Document medication decisions and prescriptions; procedural interventions and their risks; rationale for disposition—why discharge is safe versus why admission/observation is needed; shared decision-making elements when applicable; and how any SDOH affects feasibility of the plan.)

Consultations

[Consultation details] (For each consult: service and clinician contacted; clinical question; summary of recommendations; disposition ownership; and any disagreements affecting care. Omit this subsection if no consultations were obtained.)

Clinical Impression

• [Diagnosis 1 or working diagnosis] (Explicitly label uncertainty when present, e.g., "undifferentiated abdominal pain")
• [Additional diagnoses as relevant]

Disposition

Type: [Discharge / Admission / Observation / Transfer / AMA / Refusal / Elopement] | Condition: [stable / improved / unchanged / critical]

[Discharge summary] (If discharged: summarize evaluation and key findings, treatments and response, prescriptions, follow-up plan with who/when/how, diagnosis-specific return precautions, plan for pending results with notification method, and confirm discharge instructions provided including any high-risk counseling.)

[Admission/Observation details] (If admitted/observed: specify level of care, accepting service and clinician, brief risk-tied rationale, and confirm handoff with key pending items communicated.)

[Transfer details] (If transferred: document capability/resource rationale, stabilization provided, receiving facility acceptance with clinician and bed type, risks/benefits discussion or EMTALA certification, transport mode and monitoring needs, and records sent with plan for pending items.)

[AMA/Refusal/Elopement details] (If applicable: document patient's decision and stated reason; capacity assessment elements; risks/benefits and alternatives discussed; care and instructions provided despite refusal; and attempts to re-engage if patient eloped.)

Critical Care

[Critical care attestation] (Include only when critical care services were provided: describe the critical illness/injury and what made the patient critically ill; critical interventions and management; total critical care time in minutes with statement that time for separately billable procedures was excluded. Omit this section entirely if critical care was not provided.)