Effective clinical documentation is crucial in emergency medicine, where timely and accurate information can significantly impact patient outcomes. The Emergency Admission documentation involves several sections, each requiring specific details to ensure comprehensive patient care. Let's explore how to correctly write and format these documents using a structured approach.

Reason for Presentation

This section captures the patient's primary complaints at the time of arrival. For instance, a patient presenting with "severe chest pain and shortness of breath" indicates a potentially serious condition that requires immediate attention.

History of Presenting Illness

Detail the onset, description, and any additional symptoms. Include possible triggers or exposures and relevant background information. Example: "Onset of symptoms: 2 hours ago. Description: Crushing chest pain radiating to the left arm, accompanied by shortness of breath and sweating. Relevant background: History of hypertension and hyperlipidemia."

Review of Systems

Conduct a thorough review involving major systems to identify other potential issues. Example: "Cardiovascular: Chest pain, palpitations. Respiratory: Shortness of breath, no cough."

Management En Route with QAS

Document any pre-hospital treatment provided. Example: "Administered aspirin, nitroglycerin, and oxygen with partial relief of chest pain."

Past Medical History

Include relevant medical, surgical, and mental health history. Example: "Hypertension, hyperlipidemia. Appendectomy 10 years ago."

Medications

List current medications and dosages. Example: "Amlodipine 5mg daily, Atorvastatin 20mg daily."

Allergies

Note any known drug allergies. Example: "Penicillin."

Social History

Provide insights into the patient's social background. Example: "Retired teacher, lives with spouse."

Drug, Tobacco, Alcohol History

Document habits that may affect health. Example: "Occasional wine, 1-2 glasses per week. Non-smoker."

Family History

Include significant family medical history. Example: "Father had a myocardial infarction at age 60."

Immunisation History

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

Examination

Record vital signs and system-specific findings. Example: "Vitals: Blood pressure 160/90 mmHg, heart rate 110 bpm. CVS: Tachycardia, no murmurs."

Investigations

Include relevant test results. Example: "Elevated troponin levels, ECG shows ST-elevation in leads II, III, and aVF."

Assessment

Provide a primary and any secondary diagnoses. Example: "Primary diagnosis: Acute myocardial infarction."

Management in Emergency

Outline treatments provided in the emergency department. Example: "Administered morphine, continued oxygen, started IV heparin."

Plan

Detail the admission and management plan. Example: "Admit to Cardiology, Dr. Smith's team. NPO until further notice."

The documentation process can be time-consuming, which is where AI medical scribes like Notis AI Medical Scribe come into play. Notis is designed to streamline and automate the creation of patient documentation, significantly reducing the administrative burden on emergency medicine physicians.

Time Efficiency

Notis reduces documentation time by up to 80%, allowing physicians to focus more on patient care. Users can save an average of 2 hours per day on administrative tasks.

Ease of Use

With integration into familiar platforms like WhatsApp, Notis ensures a seamless transition without the need for additional software.

High Accuracy

Notis offers 99% accuracy in transcribing medical notes, ensuring reliability in documentation.

Comprehensive Documentation

By generating structured SOAP notes, Notis ensures that all essential information is captured efficiently and accurately.

In conclusion, mastering emergency admission documentation is essential for effective patient care, and tools like Notis AI Medical Scribe offer substantial improvements in efficiency and accuracy for emergency medicine physicians.