01 / ADAPTABLE OUTLINE
What to document
Presentation & information sources
Chief complaint, onset and course, pre-arrival care, pertinent history, source of information, and any history limitations.
Evaluation
Recorded vitals and trends, focused examination, diagnostic tests and interpretations, and important positive or negative findings.
Medical decision-making & ED course
Working diagnosis, serious alternatives considered, reasoning, treatment actually given, response, consultations, and reassessment.
Disposition
Status at disposition, rationale for discharge/admission/transfer, outstanding results, instructions, follow-up, and patient understanding.
02 / WORKED EXAMPLE
Minor forearm injury after a fall
Illustrative documentation only. Not patient data, a treatment protocol, or a complete billing checklist.
Presentation
An adult patient presents after striking the left forearm during a trip and fall. The patient reports localized pain without head impact, loss of consciousness, neck pain, or numbness. History is provided by the patient.
Examination & evaluation
The patient is alert and comfortable at rest. There is localized forearm bruising and tenderness without an open wound or deformity. Distal motor function, sensation, and perfusion are intact. Forearm radiographs show no acute fracture on the final report.
ED course & assessment
Left forearm contusion. Fracture was considered and imaging findings were reviewed with the patient. At reassessment, pain has improved and distal neurovascular findings remain unchanged.
Disposition
Discharged after reassessment with an individualized symptom-management plan. Follow-up was advised if symptoms persist. Return precautions include worsening pain or swelling, numbness, weakness, or color change. The patient expressed understanding.
A common documentation question
Is a longer ED note automatically better documentation?
No. Useful documentation makes the relevant findings, decisions, reassessment, and disposition understandable. Repeated or unverified text can obscure that story. This illustrative outline is not a complete checklist for every emergency presentation.
GO DEEPER / CONDITION-SPECIFIC PLANS
Treatments, doses & follow-up
A note style does not determine a treatment. Explore the condition-specific examples for sourced adult dosing references, clinical reasoning, and follow-up plans.
TRY AN INTERACTIVE EXAMPLE
HEART score, with the reasoning visible.
Select inputs, see the score, and preview the documentation. Missing answers stay incomplete.