Emergency Medicine

Emergency Department Note Template

Fast emergency documentation for presentation, initial findings, interventions, and disposition.

Blank template

Section headings in the order clinicians use them. Paste into your EHR or note tool.

  1. 1

    EMS Presentation

  2. 2

    Primary Survey

  3. 3

    EKG

  4. 4

    Labs (stat)

  5. 5

    Point-of-Care Ultrasound

  6. 6

    Clinical Assessment

  7. 7

    ED Course / Interventions

  8. 8

    Disposition

Filled example

Patient

67-year-old male, brought in by EMS

EMS Presentation

BIBA after witnessed cardiac arrest at home. Wife initiated CPR immediately. EMS arrived at 6 min, found patient pulseless with VFib rhythm on monitor. Defibrillated x3, ROSC achieved at 12 min post-arrest. Given aspirin 300 mg PR, heparin 4000 U IV en route. Transport time 14 min.

Primary Survey

Airway: intubated with 7.5 ETT (EMS, 22 cm at teeth), bilateral breath sounds confirmed.

Breathing: ventilator-assisted, SpO2 96% on FiO2 40%.

Circulation: BP 98/62 (on norepinephrine 0.05 mcg/kg/min), HR 102, regular.

Disability: GCS 3T (sedated), pupils 3mm equal and reactive.

Exposure: exposed for exam, temperature 97.8 F (post-ROSC cooling).

EKG

Sinus tachycardia ~100 bpm. STEMI pattern: ST elevation 3mm in II, III, aVF with reciprocal depression in I, aVL. Suggests inferior wall MI, likely RCA occlusion.

Labs (stat)

Troponin I: 2.84 ng/mL (elevated, consistent with acute MI)

BNP: 485 pg/mL

CBC: WBC 14.2, Hgb 13.8, Plt 212

BMP: K 4.0, Cr 1.3 (baseline 1.1), lactate 4.2

Coag: INR 1.0, PTT 28

ABG (on vent): pH 7.32, pCO2 38, pO2 88, HCO3 19

Point-of-Care Ultrasound

Cardiac: reduced EF visually estimated 35-40%, inferior wall hypokinesis. No pericardial effusion. IVC dilated, non-collapsable.

Clinical Assessment

Witnessed VFib cardiac arrest → ROSC at 12 min. Inferior STEMI on EKG. Cardiogenic shock on a single vasopressor. High-risk patient — needs emergent revascularization.

ED Course / Interventions

  1. Dual antiplatelet: aspirin (given by EMS) + ticagrelor 180 mg load via orogastric tube
  2. Anticoagulation: heparin infusion started (goal PTT 50-70)
  3. Pressor support: norepinephrine titrated to MAP >65
  4. Temperature control: target 36 C and prevent fever (>37.7 C) for at least 72 hours
  5. Cardiology paged STAT — cath lab activated
  6. Foley placed, UO monitoring started

Disposition

Emergent cardiac catheterization lab activation for primary PCI. Patient accompanied by ED physician + RN to cath lab. Handoff completed using I-PASS format. Estimated door-to-balloon time: 42 minutes.

How Notat fills this in

1

You talk with the patient

Notat listens in the background. No dictation commands, no typing during the visit.

2

Facts come first

The FactsContext™ engine extracts the clinical facts, each linked to what was said, so you can check them.

3

The note is written from those facts

Notat fills in this template from the checked facts. You review, edit, and sign.

What this format captures

This example shows the structure clinicians use to keep the important parts of a consultation clear, complete, and easy to review.

From conversation to completed note

Talk naturally with the patient. Notat identifies the clinical facts, organizes them into the right sections, and writes the note in the format your workflow requires.

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