Emergency - Template

[Larrivee]

Hey guys,

 

Just wonderin' if anyone has a nice organized template that they use for emerg consults. I find mine always get pretty ugly looking and I for some reason always treat it like an internal med consult and write a novel.

Good templates?

 

Thanks, L

[Satsuma]

Hey guys,

 

Just wonderin' if anyone has a nice organized template that they use for emerg consults. I find mine always get pretty ugly looking and I for some reason always treat it like an internal med consult and write a novel.

Good templates?

 

Thanks, L

 

 

Hmm, you mean for when you are on an emerg rotation?

 

I can't help you out with a template.

 

But the trick to getting more concise with emerg is getting more focused with your histories and physical exams. Use point form and document only pertinent negatives and pertinent positives.

 

Otherwise your general template is going to be the same as anything else: Chief complaint, HPI, meds, allergies, physical exam. Just it will be more focused details.

 

Asking "what brought you into the ER TODAY" is always helpful to help focus when a pt presents with something that's been going on for awhile. As is the question "So have you seen your family doc about this?". It sounds a little snarky, and sometimes I really wish they did go see their family doc. For the most part the answer will be - they couldn't see me until tomorrow or the next day and they didn't want to wait. Other times you'll find out they have and didn't feel they were getting anywhere and you find out their real motive is something like " I want an MRI today for my back pain I've had for 6 months" and that allows you to specifically address the concern more directly,

 

Hope that helps!

[tooty]

I divide the space in 2. id, cc, hpi, exam, investigations on the left. Small column of pmhx, pshx, meds, allergies, social on the right. Write small but legibly.

[rogerroger]

This is a good question.

 

Charting in the ED can be a tad different from the charting you will learn elsewhere as it is directed and concise.

 

The key is to have your differential well formulated in your mind. Someone reading your chart should be able to rule out/in the emergent diagnoses by reading your notes. Why you selected a final treatment plan should also be clear. The note should be short and too the point.

 

Note all procedures, reassessments, important investigations, conversations and names with consultants, and discharge instructions.

 

Feel free to use point forms, symbols etc. This is very common in ED charting and is accepted. Often key info like allergies are noted already on the chart. You should still ask about this stuff but if unchanged from whats is already on the chart I circle and initial what is already written.

 

Below is a random example of a template. There are lots of templates out there, it is very much a matter of personal preference how you organize things.