Emergency/Urgent Care Encounter Note

Patient: [Species], [Breed], [Sex/intact status], [Age], [Weight and units]

Owner/Client: [Name], [Preferred contact method and number]

Date/Time of Arrival: [Date] at [Time]

Location: [ED / Urgent Care]

Clinician(s): [Treating veterinarian(s) and credentials]

Mode of Arrival: [walk-in / referral / transport]

Referring Clinic: [Referring clinic name, clinician, contact] (Omit if not applicable)

Historian: [Owner / foster / Good Samaritan / staff / other] — [reliable / limited reliability due to reason]

Triage

(Use concise timestamped entries. If triage was bypassed due to critical status, state this explicitly rather than leaving blank.)

• [Time] Triage category: [Acuity score or category per facility system]. Immediate actions: [Actions taken]. [Pre-arrival communications if applicable]
• [Time] (Include only if triage was bypassed) Triage bypassed due to critical presentation; patient taken directly to [resuscitation area / treatment].

Chief Concern & History of Present Illness

[Chief concern in owner's words]. [Onset, duration, progression, severity, triggers, exacerbating and relieving factors, prior interventions and response]. [Pertinent negatives affecting risk assessment]. (For trauma: include mechanism, timing, and changes since event. For toxin exposure: include agent, estimated dose, time of exposure, and any decontamination attempts. If history was obtained after initial stabilization, begin with "Post-stabilization history." If history is limited or unknown, state why and document whatever information is available.)

Relevant History

(Include only information that materially affects emergency management. State "unknown" with reason if not available.)

• Active problems/chronic conditions: [Conditions directly impacting emergency care]
• Current medications: [Name, dose, route, frequency; last dose time if clinically important]
• Allergies/adverse reactions: [Agent and reaction type, or "none known"]
• Relevant vaccinations: [Status] (Include only if impacts risk assessment)
• Baseline functional status: [Mobility, appetite, mentation baseline for comparison]

Vitals & Point-of-Care Data

• [Time] Initial vitals: Temp [value], HR [bpm], RR [brpm], BP [value and method], SpO2 [%], Pain score [scale and score], Weight [value and units]
• [Time] Point-of-care results: [Glucose, lactate, PCV/TS, other POC tests and values] (Include only if performed)
• Monitoring in use: [Oxygen delivery method and flow/FiO2, ECG, capnography, blood pressure monitoring, other] (Include only if used)
• [Time] Recheck vitals: [Repeat vital signs] (Include serial entries after significant interventions to show response)

Physical Examination

(For unstable patients, document primary survey first. For stable patients, document focused exam relevant to presenting concern. State any limitations due to instability, aggression, sedation, or other factors.)

Primary Survey

(Include for unstable patients)

• Airway: [patent / obstructed / intubated] — [Key findings]
• Breathing: [Effort, pattern, auscultation, SpO2 response, thoracic excursions, abnormal sounds]
• Circulation: [Pulse quality, mucous membranes, CRT, heart sounds, perfusion parameters, hemorrhage if present]
• Disability: [Mentation, pupil size/PLR, posture, motor function, seizure activity]
• Exposure: [Temperature, injuries, wounds, environmental considerations]

Targeted System Examination

• General appearance and mentation: [Findings]
• Airway and respiratory: [Findings]
• Cardiovascular and perfusion: [Findings]
• Abdominal: [Findings]
• Neurologic: [Findings]
• Musculoskeletal and integument: [Findings]
• Examination limitations: [Reason examination was limited] (Include only if applicable)

Stabilization & Procedures

(Include this section only when time-critical interventions were performed. Document chronologically with timestamps.)

• [Time] Oxygen/ventilation: [Device], [flow rate or FiO2]. Response: [Patient response]
• [Time] Vascular access/fluids: [IV/IO/arterial], [catheter size and location]. Fluids: [Type], [bolus dose or continuous rate]. Response: [Patient response]
• [Time] Emergency medication: [Drug], [dose], [route]. Indication: [Reason]. Response: [Patient response]
• [Time] Procedure: [Procedure name]. Indication: [Reason]. Technique: [Brief description]. Findings: [Key findings]. Complications: [Any complications or "none"]. Response: [Patient response]
• [Time] Consent: [Verbal / written] obtained from [Name and relationship] for [Procedure]. Risks and benefits discussed: [Summary] (Include for non-emergent procedures)

Diagnostics & Results

(Report key results: abnormal values and clinically decisive normals. Do not include complete panels.)

• Laboratory: Ordered: [Tests] for [Indication]. Key results: [Abnormal values with units and reference direction, decisive normals]
• Imaging: [Modality] for [Indication]. Findings: [Clinician interpretation for immediate care]. (Note if formal report pending)
• ECG: [Rhythm, rate, significant abnormalities] (Include only if performed)
• Other: [Diagnostic modality and key findings] (Include only if applicable)

Clinical Course

(Chronological timestamped entries. If patient left before completion, document what was accomplished, recommendations, risks communicated, and contact attempts.)

• [Time] [Event or intervention]. Response: [Change in clinical status]. Plan update: [Any changes to plan]
• [Time] [New information affecting differential or plan]. Action: [Response taken]
• [Time] Consultation with [Service or clinician]. Recommendations: [Specific actions recommended]
• [Time] [Escalation / de-escalation] decision: [Rationale]

Assessment

(Problem-oriented, listed in order of severity. If definitive diagnosis not possible, document syndrome and uncertainty clearly.)

Problem 1: [Working diagnosis or clinical syndrome]

• Evidence: [Key findings supporting this problem from this encounter]
• Differentials: [Focused differential diagnosis]
• Risk/concern: [Why concerning and complications to monitor]

Problem 2: [Working diagnosis or clinical syndrome]

• Evidence: [Key findings]
• Differentials: [Focused differential diagnosis]
• Risk/concern: [Why concerning and complications to monitor]

(Add additional problems as needed)

Plan

(Organize by problem. Be specific about contingency actions if patient worsens.)

Problem 1: [Problem name]

• Diagnostics: [Pending tests, timing for rechecks]
• Therapeutics: [Medications with dose/route/frequency, fluids, oxygen strategy]
• Monitoring: [Parameters and frequency, reassessment interval]
• Consultation/Referral: [Service and timing] (Include if applicable)
• Contingency: If [worsening sign], then [specific action]

Problem 2: [Problem name]

• Diagnostics: [Pending tests]
• Therapeutics: [Treatments]
• Monitoring: [Parameters and frequency]
• Contingency: [Action if worsening]

(Add additional problems as needed)

Owner Communication & Consent

• [Time] Contacted [Name and relationship] via [phone / in person / other]
• Discussed: [Clinical status and acuity, diagnostic and treatment options, risks and benefits, prognosis, cost estimate if applicable]
• Decisions: Accepted: [Accepted interventions]. Declined: [Declined interventions]. (If declined against medical advice, document that risks were explained)
• Owner unavailable: [Contact attempts made, interim stabilization under emergency necessity, plan for follow-up communication] (Include only if owner was unavailable)

Disposition

• Type: [discharged home / hospitalized to ward / hospitalized to ICU / transferred / euthanasia / left AMA / LWBS]
• Time of disposition decision: [Time]
• Status at disposition: Vitals [values], Mentation [description], Pain [score], Respiratory status [description]
• Final or working diagnoses: [Diagnoses]
• Follow-up plan: [When and where to recheck, who will communicate pending results]
• Discharge details: [Discharge instructions provided, medications prescribed with dosing, activity restrictions, return precautions discussed] (Include only if discharged)
• Admission details: [Summary of admission orders and handoff to inpatient team] (Include only if admitted)

Transfer Documentation

(Include only if patient is transferred to another facility)

• Receiving facility: [Name]. Accepting clinician/service: [Name or service]
• Transport: [Owner transport / ambulance / other]. En route support: [Oxygen, fluids, monitoring as applicable]
• Records sent: [Medical record summary, imaging, labs, treatment summary]
• Condition at departure: Vitals [values], Ongoing treatments [list]

Critical Care Time

(Include only when critical care was provided)

• Critical status: Patient was critically ill/injured with threat to life or organ function due to [Condition]
• Total critical care time: [Number] minutes (excluding separately billable procedures)
• Activities included: [Clinical management, coordination of care, record review, owner communication regarding critical decisions]
• Procedures excluded from time calculation: [List of separately billable procedures]

(For missing information affecting clinical interpretation, risk assessment, or consent documentation, use explicit statements such as "unknown at time of presentation" or "unable to obtain due to [reason]" rather than leaving sections blank. Omit optional sections entirely when they do not apply.)