Provider: 

TIME/DATE:

 

CC: Urgent ER evaluation for []

 

HPI: []

 

ROS: As documented in HPI

 

RECORDS REVIEWED: [Prior inpatient]

 

Relevant PSFH HX: []

 

PHYSICAL EXAM:

Vitals: 

 

Exam: 

 

RESULTS:

Lab and/or imaging result summary: See MDM/Re-exams

 

EKG: Time: []  Rate: []

Sinus rhythm

No ectopy

Normal P/QRS/QT intervals

Cannot exclude ischemia.

Interpreted by: Self

 

DDX: []

 

MDM: []

 

RE-EVALUATIONS:

[]

 

PROCEDURES: 

[N/A]

 

CALLS/CONSULTS: 

[N/A]

 

DIAGNOSIS: []

 

DISPOSITION: []

 

I had an extensive discussion with the patient and/or family about their disposition and they agreed with the plan. 

 

[DISCHARGE INSTRUCTIONS:

 

In addition to written instructions upon discharge, return precautions and followup instructions were extensively discussed with the patient. They verbally acknowledged understanding of these instructions without any apparent barriers to learning.

 

When the patient was discharged from the ED, the patient was given specific instructions and information regarding their illness. The patient was verbally instructed to return to the ER urgently for any worsening symptoms OR failure of symptom improvement over the next 12-24 hours and this was also written in the discharge instructions. In the patient’s discharge instructions I told them to follow-up with their primary care provider in 1-2 days as well as to follow-up with any specialists as necessary. If they did not have a primary care provider I gave them an alternate clinic to call and make an appointment. I also included diagnosis-specific educational material in their discharge paperwork.]

 

 

LABS/RADIOLOGY READS: