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EMERGENCY NOTE

ID:
[]

SUBJECTIVE:
[What is the patient telling you]

OBJECTIVE:
[Physical Examination and Special Investigations]

ASSESSMENT:
[]

COURSE IN ED:
[]

PLAN:
[]

This document was created using voice recognition software and as a result might contain some errors. If anything is not clear, please do not hesitate to contact me.

Dr []
EMERGENCY VISIT:

IDENTIFICATION:
[]

SUBJECTIVE:
[]

PREVIOUS MEDICAL HISTORY: 
[]

MEDICATION HISTORY: 
[]

OBJECTIVE:
Vitals: []

[]

ASSESSMENT:
[]

SPECIAL INVESTIGATIONS:
[]

COURSE IN ED:
[]

PLAN:
[]


This document was created using voice recognition software and as a result may contain some errors. Do not hesitate to contact me if anything is unclear.

Dr []
EMERGENCY CONSULTATION

Referred by: []

MOST: []

REASON FOR REFERRAL:
[]

IDENTIFICATION:
[] 

SUBJECTIVE: 
[]

PREVIOUS MEDICAL HISTORY:
[]

ALLERGIES:
[]

MEDICATIONS:
[]
OBJECTIVE:

Vitals: []
Examination:
General: []
Chest: []
CVS: []
Abdomen: []
Neurology: []

ASSESSMENT AND PLAN:
[]


Thank you for involving my in this patients' care.

This note was created with voice recognition software and may contain some errors. If anything is unclear, please do not hesitate to contact me.

Dr []

IDENTIFICATION:
[]

TRAUMA TEAM MEMBERS:
1.	[]

MECHANISM OF INJURY:
[]

MODE OF ARRIVAL:
[Ambulance] [Medivac][Self]

DEATH AT SCENE: 
[Not applicable]

PRIMARY SURVEY:
A: [Maintained]
B: [Able to communicate]
C: [Good perfusion and peripheral pulses]
D: GCS [], AVPU=[]
E: [Patient exposed and warmed]

RX:
1.	O2: []
2.	IV Access: []
3.	IV Fluids: []
4.	Blood: []
5.	Catheter: []
6.	Intubation: []
7.	E-FAST:
a.	Lung: [Normal lung sliding], [No pleural effusion]
b.	Cardiac: [Cardiac Activity] [No pericardial effusion]
c.	Abdo: [No free fluid]
d.	Aorta: [Normal calibre , 3cm]

SECONDARY SURVEY:
MAIN COMPLAINT:
[]
HISTORY:
 
ALLERGIES: 
[NO KNOWN ALLERGIES]

MEDICATIONS:
[None]

PREVIOUS MEDICAL HISTORY: 
[None]

PREVIOUS SURGICAL HISTORY: 
[None]

LAST MEAL: []

EVENTS:
[]

COMPLETE EXAMINATION:
General: []
Respiratory: []
Cardiovascular: []
Abdomen: []
Neurological: []
MSK: []

SPECIAL INVESTIGATIONS:
1.	Urine: []
2.	Erect CXR: [No pneumothorax, no hemothorax, no rib fractures. No widening of mediastinum, no free air under diaphragm]
3.	Pelvis XR: [No pelvic fractures, all rings are intact]
4.	C-Spine XR: [Alignment normal, all three columns appears intact, no swelling to suggest soft tissue or possible fracture]
5.	Trauma CT: 
a.	BRAIN: [N/A]
b.	C-SPINE: [N/A]
c.	CHEST: [N/A]
d.	ABDO: [N/A]
e.	PELVIS: [N/A]
6.	LABS:
a.	CBC: Hb [], PLT []
b.	Renal: Creatinine [], GFR [], Urea [], Na [], K []
c.	LFT: TB [], ALT [], AST [], ALP [], GGT [], LDH []
d.	TROP: []

ASSESSMENT: 
1.	[List injuries and management for each]
2.	Pain: [Hydromorphone 0.5 – 1mg every hour prn]

CONSULTS:
1.	[]

DISPOSITION: 
[]

This document was created using voice recognition software and as a result may contain some errors. Do not hesitate to contact me if anything is unclear.

Dr []

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