Emergency Department Encounter Note (Student)

Date/Time: [Encounter date and time of student evaluation]

Location: [ED site and room/bed if applicable]

Patient: [Identifiers per institutional standard]

Author: [Student name], Medical Student, [Training year]

Supervising Clinician(s): [Resident and/or attending names and roles]

Chief Complaint

[Patient-stated reason for ED visit] (Use patient's words when clinically meaningful—e.g., pain description, assault disclosure, suicidality.)

[Triage complaint] (Include only if it differs from patient report.)

Triage & Prehospital

(Include this section only when prehospital or triage information meaningfully informs clinical decisions; omit entirely if not applicable.)

• [Mode of arrival and prehospital timeline]
• [Prehospital treatments and patient response]
• [Pertinent triage findings or concerns]

History of Present Illness

[Focused narrative HPI] (Open with relevant patient context and presenting symptom(s). Characterize onset, duration, location, quality, severity, timing, provoking and palliating factors. Include pertinent associated symptoms—positives and high-value negatives that narrow the differential. Add contextual factors only when they inform the workup: exposures, trauma mechanism, substance use, medication nonadherence, pregnancy possibility. Note prior evaluation or treatment for this complaint and response. Document baseline when relevant—e.g., oxygen requirement, functional or mental status. End with history reliability and source, noting limitations explicitly and interpreter use when applicable.)

Relevant History

(Include only elements that informed this ED evaluation; omit categories that did not inform care rather than writing "noncontributory.")

• PMH: [Major conditions and high-risk diagnoses relevant to today's problem; include anticoagulation status, immunocompromise, pregnancy status when relevant]
• PSH: [Surgeries relevant to the complaint]
• Medications: [Home medications relevant to complaint or risks] (Note if full medication list was reviewed.)
• Allergies: [Allergen and reaction type]
• Family/Social: [Directly relevant details only—e.g., early CAD, housing affecting disposition, substance use]

Review of Systems

(Complaint-driven; include pertinent positives and high-value negatives that support or narrow the differential. Avoid broad "all other systems negative" statements.)

• [Pertinent positives]
• [High-value negatives relevant to differential]

(If ROS is limited, state the reason—e.g., "ROS limited due to altered mental status.")

Physical Exam

(Document only what was actually performed. Include pertinent negatives that meaningfully impact the differential.)

• General: [Appearance, distress level, toxic vs nontoxic, work of breathing]
• Vital signs: [Vital signs used for decision-making; include repeat vitals if clinically important]
• [Targeted system exams]: [Findings for systems relevant to the complaint] (Organize by system—e.g., Cardiovascular, Respiratory, Abdomen, Neuro, Skin, Psych. Include only systems actually examined.)

Diagnostics

(Include this section when diagnostic studies were obtained or reviewed; omit entirely if none.)

• Laboratory: [Salient abnormal values and key decision-driving normals]
• Imaging: [Study name and impression; highlight decision-relevant findings]
• ECG: [Time obtained]; reviewed with supervising clinician (Avoid independent interpretation unless permitted per site policy.)
• Point-of-care/Ultrasound: [Study and key findings]
• Pending studies: [List with responsible party for follow-up per local policy]

ED Course & Medical Decision Making

(Organize by problem in decreasing acuity. For dangerous diagnoses, explicitly document how they were evaluated. When a test or treatment a reasonable clinician might expect was not performed, document why.)

[Problem 1]: [Working diagnosis / primary concern]

Problem statement: [Concise description with diagnostic uncertainty acknowledged when present]

• Differential diagnosis: [Top 3–6 plausible diagnoses including critical "can't miss" conditions]
• Initial plan and rationale: [Tests and treatments ordered and why; include tests considered but deferred with reasoning]
• Results synthesis: [How new data changed diagnostic probability and management]
• Treatments and response: [Interventions given and observed response]
• Reassessment: [Time or relative time]; [Updated exam, vitals, or symptoms after key interventions or results] (Include at least one reassessment after significant interventions or result returns.)
• Consultant input: [Service and key recommendations] (Include if discussed.)
• Disposition reasoning: [Why the chosen disposition is safe and appropriate for this problem]

[Problem 2]: [Secondary concern]

(Include only if additional problems were explicitly addressed; repeat same structure as Problem 1.)

Procedures

(Include when a procedure was performed or directly observed; omit entirely if none.)

[Procedure name]

• Indication: [Clinical reason]
• Consent: [Type of consent obtained]
• Time-out: [Verification performed]
• Technique and findings: [Brief description of technique and pertinent findings]
• Complications: [None / description if any]
• Patient tolerance: [Tolerance and sedation details if applicable]
• Supervision: [Direct supervision / performed by student / performed by supervisor]

(Repeat subsection for each additional procedure.)

Consultations

(Include when consultants were involved; omit entirely if none.)

• [Service consulted]: [Reason for consult]; [Consultant name]; [Key recommendations]; [Disposition outcome: accepting admission / recommendations only / pending]

Disposition

Final disposition: [discharge / admit / observation / transfer / AMA / eloped] (Include service and level of care if applicable.)

Condition at disposition: [Objective anchors—e.g., improved, tolerating PO, repeat vitals stable]

Final ED diagnoses:

• [Diagnosis 1]
• [Diagnosis 2]

Follow-up & Return Precautions

DRAFT — Requires supervising clinician review before finalization.

• Follow-up: [Who to follow up with]; [Timeframe]; [Referral placed / patient to arrange]
• Pending results: [Studies pending and responsible party for follow-up per local policy]
• Medications: [New prescriptions and medication changes with key safety counseling]
• Return to the ED immediately for: [General deterioration warnings—worsening pain, trouble breathing, fainting, confusion—and condition-specific red flags with timeframes] (Avoid guaranteeing outcomes; use specific timeframes rather than open-ended "if symptoms persist.")

Signatures

Student Signature: [Electronic signature with role and timestamp]

Supervising Clinician Attestation: [Attestation that the supervising clinician saw and examined the patient, reviewed student documentation, and agrees with or modifies the plan] (This area is separate from the clinical narrative; use for any amendments to student documentation.)