Correctly writing and formatting clinical documentation in emergency medicine is crucial for effective patient care and communication among healthcare professionals. In this tutorial, we will explore the template used for ED Admission documentation, providing a detailed walkthrough to ensure high standards in patient charting.

Reason for Presentation

This section should clearly explain why the patient is seeking emergency care. For example, "55-year-old male presents with chest pain and shortness of breath." This concise statement sets the scene for further documentation.

History of Presenting Illness

Detail the patient's symptoms and history leading up to the presentation. For instance, "The patient, accompanied by his wife, experienced severe chest pain radiating to the left arm, starting two hours ago, accompanied by nausea and sweating. No known triggers; the patient was at rest."

Management En Route with QAS

Document any interventions performed before arrival at the emergency department. Example: "Administered aspirin and oxygen; pain reduced slightly, and oxygen saturation improved."

Past Medical History

Include relevant medical history that could impact current care. For example, "History of hypertension and hyperlipidemia; appendectomy in 2005."

Medications

List all current medications with dosages. Example: "Lisinopril 10mg daily, Atorvastatin 20mg daily."

Allergies

Clearly state any known allergies. For example, "Penicillin."

Social History

Provide context about the patient's lifestyle and support system. Example: "Works as an accountant, lives with wife and two children."

Drug, Tobacco, Alcohol History

Summarize substance use. Example: "Social drinker, 1-2 glasses of wine per week; non-smoker; no illicit drug use."

Family History

Note any familial conditions that may affect the patient's health. Example: "Father had a myocardial infarction at age 60."

Immunisation History

Ensure vaccinations are up to date. Example: "Up to date with vaccinations."

Examination

Document the findings from the physical exam. Example: "Vitals: Blood pressure 150/90 mmHg, heart rate 95 beats/minute, oxygen saturation 94%. General: Alert and oriented, appears anxious."

Investigations

Include any diagnostic tests performed. Example: "Elevated troponin levels, chest X-ray shows no acute findings, ECG indicates ST elevation in leads II, III, and aVF."

Assessment

Provide a clinical assessment based on findings. Example: "Acute myocardial infarction and hypertension."

Management in Emergency

Outline immediate management steps taken in the emergency department. Example: "Administered nitroglycerin and morphine, transferred to cardiac catheterization lab."

Plan

Detail the ongoing management plan. Example: "Admit to Cardiology team, continuous cardiac monitoring, transfer to ICU post-procedure."

In the fast-paced environment of emergency medicine, efficient documentation is essential. AI medical scribes like Notis AI Medical Scribe offer a transformative solution by automating the creation of clinical notes, particularly in specialties like emergency medicine. Notis uses advanced voice-to-text technology to transcribe interactions into structured SOAP notes, significantly reducing the time physicians spend on documentation.

Benefits of Notis AI Medical Scribe

Notis enhances time efficiency by cutting down documentation time by up to 80%, allowing emergency medicine physicians to focus more on patient care. Its integration with WhatsApp provides a user-friendly interface, and with 99% transcription accuracy, it ensures reliable clinical notes. Notis also supports multilingual documentation, catering to a diverse patient population. By automating documentation, Notis minimizes administrative burdens, enhancing both productivity and job satisfaction for healthcare providers.

In summary, mastering the art of ED Admission documentation is vital for effective patient care. By leveraging tools like Notis AI Medical Scribe, emergency medicine physicians can streamline their documentation process, enhancing both efficiency and accuracy in patient charting.