Emergency Department Reassessment/Progress Note

ED Reassessment/Progress Note

Date/Time: [date and time of documentation]

Reassessment Time: [actual time of clinical reassessment] (Include only if different from documentation time; otherwise omit this line.)

Initial Note Reference: See initial ED provider note for full HPI/PMH/ROS.

Reason for Reassessment

[One-sentence reason for this update: post-intervention check / new result / change in status / boarding update / pre-discharge evaluation]

ED Course (Interval Events)

(Time-stamped bullets capturing events since the last provider evaluation. Format: time → event → patient response or clinical meaning. Only include events that actually occurred.)

• [time → event → patient response/clinical meaning]
• [time → event → patient response/clinical meaning]

Reassessment

Subjective: [Symptom trajectory: improved / unchanged / worsened]; [new symptoms]; [functional status]; [patient preferences or decisions] (Use direct quotes only for refusals, capacity-relevant statements, or high-risk shared decisions.)

Objective:

• [Current vital signs with trends]
• [Targeted exam findings relevant to presenting complaint and disposition]
• [Key bedside data] (Include only if applicable.)

(If any expected element could not be reassessed, explicitly state why and what alternative data were used, e.g., "Not reassessed—patient in imaging.")

Updated Assessment

[Working diagnosis]: [improving / stable / worsening]. [Brief supporting evidence from new data or response to therapy.]

• [Differential update: diagnoses moved up or down based on new information] (For high-risk complaints, explicitly state which dangerous diagnoses remain concerns versus are less likely.)
• [Relevant risk factors influencing disposition] (Include only if they affect decision-making; otherwise omit.)

Plan and Disposition

• Therapeutics: [continue / start / stop] [medication/therapy with dose/route/frequency]
• Diagnostics: [pending tests with expected timing and decision thresholds] (Omit if none pending.)
• Monitoring: [observation plan, reassessment triggers]
• Disposition: [pending / admit / discharge / transfer]; [criteria to meet before disposition if pending]; [confirmation that reassessment occurred immediately prior if discharging]
• Return Precautions: [high-risk return precautions specifically reviewed with patient]
• Shared Decision-Making: [options presented, patient understanding, agreed plan] (Include only if relevant to this reassessment; otherwise omit.)

(If information is missing or result pending, use explicit placeholder language. Omit bullet points that are not relevant to this particular reassessment.)

Critical Care Addendum

(Include this section only if critical care time is being billed; otherwise omit entirely.)

• [Critical illness criteria met]
• [Critical interventions performed]
• [Total critical care time in minutes]