OVERVIEW
KEY COMPONENTS OF THE NOTE
Chief Complaint:
History of Present Illness (HPI):
Past Medical History:
Past Surgical History:
Allergies:
Medications:
Family History:
Social History:
Review of Systems:
Physical Exam:
Vital Signs:
Constitutional:
HEENT:
Respiratory:
Cardiovascular:
Abdominal:
Neurological:
Psych:
ED course & Medical Décision Making
Lab tests/interpretation
Imaging/interpretation
Medications received/effect
Discharge/transfer plan
Conditions:
Disposition:
Final impression:
Follow up plan:
BLANK TEMPLATE
OTHER
Page updated: 05.06.2016