MEDICAL STUDENT NOTE TEMPLATE

  • You can copy and paste this template into a blank note
  • Document a Chief Complaint on ALL charts.
  • Perform and document your OWN History.
  • There should be 4 Elements in the HPI for complex workups.
  • Perform and document a complete ROS on complex workups.
  • You can document 10 separate systems OR document all pertinent positives and negatives, and check “All Other Systems Are Negative” box.
  • Document Past Medical, Social, and Family Histories on patient with complex workups.
  • Perform and document a Physical Exam containing 8 Organ Systems on your more complex cases.
  • Document your differential diagnoses—
  • for simple chief complaints you should have at least TWOe.g. Ankle pain, differential diagnosis: ankle sprain, ankle fracture
  • for complex chief complaints you should have at least THREE e.g. abdominal pain in a female: ovarian torsion, appendicitis, UTI, etc.
  • In ED course, briefly summarize interventions and patient response/change (eg orthopedic reduction with outcome)

Your chart should tell the story of your patient—we should be able to understand their full history, what brought them into the Emergency Department, what happened while in the ED, and what the plan (disposition) was for the patient—whether they were admitted, discharged, etc.

For each week in the ED you must send 2 notes for review. After the second week send 4 notes, and a final 4 notes at the end of the rotation. Please make a copy into a Word document, remove the patient identifiers, and send to Dr. Goodwin at

While in the ED, please choose the option for “student” under the category “emergency medicine” and do NOT designate a co-signer.

STUDENT EMERGENCY DEPARTMENT HISTORY AND PHYSICAL EXAM

(This note is for teaching purposes and not part of the official medical record)

Date:@IPTODAYDATE@

Patient Name: @NAMEREVERSE@

Student name: @me@

History of Presenting Illness:
Chief Complaint:

History obtained from:

Interpreter used:

PMD:

Past Medical History:
Past Surgical History:
Family History:
Social History:
Allergies:

@ALLERGY@

Medications:

@MEDSCURRENT@

Review of Systems:
Physical Exam:

VS: @VS@

Constitutional:

Appearance:

Head:

Eyes:

ENT:

Neck:

Respiratory/Chest:

Cardiovascular:

Abdomen:

Genitourinary:

UpperExtremity:

LowerExtremity:

Neurological:

Skin:

Lymphatic:

Psychiatric:

Assessment/Plan:

Differential Diagnosis:

ED Course:
Labs:

@LAB24@

Rads:

@RADRSLT@

Clinical Impression:

Final Diagnosis:

ED disposition:

Follow up plan (if discharged):

New Prescriptions: