How to Write a Note in the ED, and How to Present your Case.

Note Format:

em-note-format

HPI: use OPQRST or OLDCARTS to organize your questions, or the approach recommended per the CC, as described in other posts .

How to Present Your Case:

Work through the structure of your note. If you always stick to the same format of the note, you will learn a mental picture that you can use as a format for your presentation.

em-note-format-numbered-for-presentation

1.,2.) ID +CC: “Here is a __ y/o Male/Female, with chief complaint of __.

3. PmHx: “List of pertinent PmHX, (ie. patient is 14 wks pregnant).”

4. Meds: if appropriate to complaint. (ie. antihypertensive meds for gestational HTN.

5. HPI: This is where things get interesting, but only after you set the stage with the above steps 1 through 4. Do not start this presentation until you have a DDX, make a mental list of:

  • Diagnoses you must exclude (can’t miss) given this CC.
  • Dx that are common for this CC.
  • A more thorough DDX can be obtained by the following mnemonics (most useful when you are starting to learn EM):
VITAMINC&D: STIMPVD:
V Vascular S Structural
I Infectious T Trauma/Toxin
T Trauma/Toxin I Infectious/Iatrogenic/Ingestion
A Acquired M Metabolic/Endocrine
M Metabolic P Pregnancy/Psych
I Iatrogenic V Vascular
N Neoplastic D Drugs/Meds
C Congenital
D Degenerative
E Endocrine

Organize your Symptoms according to your DDX:

(This is key to keep your preceptor interested, if it is not organized, their attention will drift off)

This is likely the most cognitively challenging part of the case presentation. You will need to focus on one Dx at a time, and recall the symptoms that support/refute the proposed Dx. Then move onto the next Dx.

6. On Exam (O/E):

  • Force yourself to copy the vitals in your note, this forces you review them, (check for SIRS Criteria, or qSOFA).
  • Organize these findings according to DDX as well.

7. Labs Values, or Prior Investigations:

8. Your Assessment/Plan:

  • Symptom Relief you recommend.
  • Differential Diagnosis.
  • Investigations.
  • Treatment options, according to results of investigation.
  • Disposition: admission vs going home vs followup care.

 

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