The Emergency Department (ED) note is a formal document recording a patient’s entire encounter, from arrival to departure. This note serves multiple functions, acting as the official medical and legal record of the care provided. It is the primary tool for communicating the patient’s condition and the clinician’s thought process to other healthcare providers involved in subsequent care. Furthermore, this documentation is the foundation for medical billing, justifying the complexity of services rendered, and provides medicolegal protection by logging treatment decisions.
Documenting the Patient’s History
The initial portion of the ED note captures the patient’s subjective experience, provided directly by the patient or their representative. This begins with the Chief Complaint (CC), a concise statement describing the main reason they sought emergency care. Following the CC is the History of Present Illness (HPI), which details the symptom’s onset, location, quality, severity, timing, and any factors that alleviate or aggravate it. This structured approach ensures all pertinent aspects of the current problem are recorded, establishing context for the provider’s investigation.
To understand the current illness, the provider documents a Review of Systems (ROS), an inventory of symptoms across various body systems. The note highlights symptoms that are present (pertinent positives) and those absent but relevant to the differential diagnosis (pertinent negatives). This information is crucial for identifying related issues the patient may not have considered important.
The provider collects background information, including the Past Medical History (PMH), which lists previous diagnoses, surgeries, allergies, and current medications. For an acute ED visit, documentation focuses on PMH elements clinically relevant to the present complaint, such as a history of heart disease in a patient with chest pain. Similarly, the Social History (SH) and Family History (FH) are recorded, focusing on elements like tobacco use, alcohol consumption, or inherited diseases that may influence the presentation or treatment plan.
Recording Objective Clinical Findings
The note transitions to objective data, consisting of measurable and observable facts collected by the medical staff. This section begins with the Vital Signs (VS), the body’s functional indicators, including temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation. Abnormal vital signs often signal the severity of the patient’s condition and may prompt immediate intervention.
Next is the documentation of the Physical Examination (PE), a systematic evaluation where the provider assesses the patient’s general appearance and examines specific organ systems pertinent to the chief complaint. The note details observable findings, such as the skin’s condition, specific sounds heard when listening to the heart or lungs, and tenderness found during the abdominal exam. This record ensures that the documented findings directly support the subsequent assessment.
The objective section includes all diagnostic tests ordered during the ED stay, such as laboratory studies and imaging reports. Laboratory results, like a complete blood count or cardiac enzymes, are documented alongside finalized reports for imaging studies like X-rays, CT scans, or ultrasounds. This data provides measurable evidence that either confirms or helps to rule out potential diagnoses. The documentation of these findings is distinct from the interpretation, which is reserved for the assessment section.
Medical Decision Making and Treatment
The Assessment section of the ED note synthesizes the subjective history and objective findings into a working diagnosis or the Differential Diagnosis (DDx). The provider outlines their clinical impression, often starting with a concise summary of the patient’s presentation and the most likely diagnoses. This section documents the initial clinical reasoning.
The Medical Decision Making (MDM) portion is the narrative explanation of the provider’s thought process and is important for both patient care and billing. It justifies the complexity of the encounter by explaining why certain tests were ordered, why a particular diagnosis was favored, and how the patient’s risk level was determined. The MDM demonstrates the skill and consideration applied to managing the patient’s condition.
The ED note provides a detailed record of all treatments administered during the visit, collectively known as the Plan. This includes all medications given, such as pain relievers or antibiotics, along with the route and time of administration. Procedures performed, such as suturing a laceration, setting a fractured bone, or performing a cardioversion, are also documented. The note also records any consultations with specialists, including the consulting physician’s name and their specific recommendations.
Disposition and Discharge Planning
The final section of the ED note documents the patient’s disposition, which is the determination of their next destination following the ED evaluation. This decision is categorized as discharge home, admission to the hospital for further inpatient care, or transfer to another facility. The documentation must clearly state the rationale for the chosen disposition, especially for high-risk conditions.
If the patient is discharged, the note must include detailed instructions for self-care and a plan for follow-up. This includes specific discharge instructions, any new prescriptions provided, and necessary precautions the patient must take. The document must also reflect that the patient received and understood the education regarding their condition, treatment, and when to return to the ED if symptoms worsen. This record confirms the patient’s capacity to comprehend the instructions and ensures a safe transition out of the emergency setting.