While in the ED, it is imperative to learn the importance of good documentation. Writing a well constructed chart will help you with your thought process as you work through a differential diagnosis based on a chief complaint, why/how you ordered specific tests, your interpretation, and ultimately the patient’s disposition.
In order to help you practice this, you can use the below document as a guide. Feel free to download and print out for guidance during shifts. Try to fill out the historical features, physical examination and differential before presenting to your senior resident or attending.
- Altered Mental Status
- Chest Pain
- Shortness of Breath
- Female Abdominal Pain
- Male Abdominal Pain
- Overdose/Psychiatric Complaint
- Back Pain
- Endocrine related complaint ( DKA, HHNK, Thyrotoxicosis, etc)
- Pregnancy Related Complaint.