Emergency medicine
Emergency department note template
A time-critical ED structure: triage category, focused history and examination, risk score, investigations, reassessment and an explicit disposition decision.
Best used for
- Emergency departments
- Urgent care centres
- Acute assessment units
- Ambulatory emergency care
Template structure
Each section shows what to document and a worked clinical example.
Arrival time and mode, triage category, presenting complaint in the patient's words, and the initial set of observations.
Example
Self-presented 21:14, triage category 3. Central chest pain for two hours. Initial observations: HR 88, BP 142/86, RR 16, SpO2 98%, T 36.8 C.
Targeted history with time-critical features, cardiac and respiratory risk factors, and a focused examination relevant to the presentation.
Example
Central heaviness radiating to left arm, onset at rest, no exertional pattern previously. Hypertension, ex-smoker. Chest clear, heart sounds normal, no calf tenderness, equal pulses.
Investigations ordered with results and timings, and the named risk score used with its value.
Example
ECG at 21:20: sinus rhythm, no ischaemic change. Troponin at 21:30 undetectable, repeat at 00:30 undetectable. HEART score 3 — low risk.
State the reassessment, the disposition decision with its rationale, discharge advice, and follow-up arranged.
Example
Pain-free on reassessment at 00:45, observations stable. Low-risk chest pain, safe for discharge. Advised to return immediately for recurrent pain, breathlessness or syncope. GP review within one week, outpatient cardiology referral sent.
Documentation tips
- Timestamp investigations and reassessments; ED notes are read as a timeline.
- Name the risk score used and its value — 'low risk' alone is not defensible.
- Document the disposition rationale, especially for discharge decisions.
Frequently asked questions
- What makes an emergency department note defensible?
- Timestamps, an explicit risk stratification, documented reassessment, and a clear disposition rationale with safety-netting advice.
- How detailed should an ED history be?
- Focused rather than comprehensive: the time-critical features that drive the differential and the disposition decision.
- Can ambient AI keep up with an ED workflow?
- Yes for the narrative sections. Timestamped investigation results are typically confirmed by the clinician during review.
- Does this template work for urgent care?
- Yes. The triage, focused assessment and disposition structure applies directly to urgent care documentation.
More templates
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