Emergency Department Visit Note

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

Emergency Medicine Note

Chief Complaint:
[Chief complaint in patient's own words]

History of Present Illness:
[Chronological description of presenting symptoms, onset, duration, severity, associated symptoms, relevant context or events]

Past Medical History:
(hyphenated list)
- [Relevant medical conditions]

Past Surgical History:
(hyphenated list)
- [Relevant surgical procedures]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]

Allergies:
(hyphenated list)
- [Allergen and reaction]

Social History:
(hyphenated list)
- [Tobacco use: type, amount, duration]
- [Alcohol use: type, amount, frequency]
- [Recreational drug use: type, amount, frequency]
- [Occupation]
- [Living situation]

Family History:
(hyphenated list)
- [Relevant family medical conditions]

Review of Systems:
(hyphenated list)
- [Pertinent positives and negatives by system]

Physical Examination:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [General appearance]
- [HEENT: findings]
- [Neck: findings]
- [Cardiovascular: findings]
- [Respiratory: findings]
- [Abdomen: findings]
- [Genitourinary: findings]
- [Musculoskeletal: findings]
- [Neurological: findings]
- [Skin: findings]
- [Psychiatric: findings]

Investigations:
(hyphenated list)
- [Lab results with units]
- [Imaging results]
- [Other relevant studies]

Assessment:
(hyphenated list)
- [Primary diagnosis and reasoning]
- [Differential diagnosis if applicable]

Plan:
(hyphenated list)
- [Immediate interventions performed in ED]
- [Medications administered]
- [Further investigations ordered]
- [Consultations requested]
- [Disposition: admit, discharge, observation, transfer]
- [Follow up instructions]
- [Return precautions]