While in the ED, it is imperative to learn the importance of good documentation. Writing a well constructed chart will help you with your thought process as you work through a differential diagnosis based on a chief complaint, why you ordered specific tests, your interpretation, and ultimately the patient's disposition.
By the end of your rotation, fourth year medical students will be expected to turn in ONE patient write-up for evaluation. Please email your case write up to both Dr. Ng and Dr. Crossman at the end of your rotation.
They do not necessarily have to be patients you saw primarily. Please use the Word template listed below to type up your patient write-ups. We are especially interested in your differential diagnosis and how you would treat one of the life threatening cases.
Date/Time Seeing Patient:
Chief Complaint:
The HPI is one of the most critical aspects of your documentation.
It is important to include a detailed history with pertinent positives and negatives.
Review of Systems (pertinent +/-)
Past Medical History/Meds:
Allergies:
Past Surgery History:
Social History:
Family History:
The majority of your grade will be focused on the medical decision making section
DDX: Serious/life threatening diagnosis
Differential Diagnosis?
What do you think is most probable?
Are certain life threats highly likely or unlikely given history, physical exam, or decision rules? If so, DISCUSS HERE!
How will you rule out/work up potential life threats? What are you going to order?
RESULTS:
Tests Ordered/Results Interpretation
Reevaluations (include time, vitals, repeat examination)
Procedure Note (If applicable):
Diagnosis:
Disposition: Home Admit Transfer
Discharge Instructions/Return precautions: