i.e. Chief Complaint: Cough

i.e. Nursing Note: pt, a&ox3, walk-in c/o cough and fever x 1 week. denies cp and n/v/d. EKG done…

Components of Physician Note (using EPIC):

• HPI

• ROS

• PE

• Assessment & Plan

• ED course/Reassessment

• Diagnosis

• Disposition

• Sign-off

HPI (History of Present Illness)

Dot smart phrases I usually use: .edhpi (name of the smart phrase varies by hospital)
which autopopulates the patient’s name, age, sex, and past medical history available in their records. It usually looks like “John Smith is a xx-year-old male with a past medical history of CAD. The patient presents to the ED with complaints of […]” I delete the […] icon and begin typing the HPI information.

Example:
Sally Watson is a 73 y/o F with a past medical history of COPD.

The patient presents to the ED with complaints of productive cough with yellow-white sputum x 1 week. Pt describes her cough as constant and disrupting her daily activities and sleep. Due to this, pt states she has been more fatigued than usual. Pt has had four occurrences of pneumonia this year with one occurrence recently that improved with antibiotics. Pt has tried cough syrup for sx with some relief. Pt additionally c/o malaise and R-sided rib pain that started after coughing began. Pt describes rib pain as pleuritic and a 7 out of 10 in severity. The pain improves with manual compression of the area. Pt has a rescue inhaler and a long-acting inhaler at home. Pt reports using her rescue inhaler more frequently than usual, upwards of 6x/day. Pt denies n/v, abd pain, cp, HA, sob, and any other complaints at this time.

ROS (Review of Symptoms)

A series of checkboxes of pertinent positive and negative symptoms of the patient (this is subjective like the HPI). I created my own Macro for this section to have a set of pertinent negatives that automatically gets clicked negative after you press the macro button (some providers don’t like this and prefer a more limited ROS, so play it by ear).
Below I listed almost all the options you will see in the ROS to either leave blank, click (-) if it is a pertinent negative symptom, or right-click (+) if it’s a pertinent positive. YOU DON’T CLICK EVERY SYMPTOM (-) EVEN IF THE PT DOESN’T HAVE IT! Pertinent negatives are usually a few symptoms the provider asks the patient and they deny having at the end of the initial assessment.

Const:

(-) fever
(-) chills

Eyes:

(-) blurred vision
(-) double vision

HENT:

(-) sore throat
(-) hearing loss
(-) ear pain
(-) rhinorrhea ← runny nose
(-) congestion
(-) epistaxis ← nose bleed
(-) hoarseness

Resp:

(-) cough
(-) shortness of breath
(-) wheezing
(-) sputum production

CV:

(-) chest pain
(-) palpitations
(-) leg swelling

GI:

(-) abd pain
(-) diarrhea
(-) nausea
(-) vomiting
(-) melena ← dark stool

GU:

(-) dysuria ← pain when urinating
(-) frequency
(-) hematuria ← blood in the urine

MSK:

(-) arthralgia ← joint pain
(-) myalgias ← body/muscle aches
(-) back pain
(-) neck pain

Neuro:

(-) headache
(-) dizziness
(-) seizures
(-) light-headedness
(-) syncope ← loss of consciousness

Skin:

(-) rash
(-) erythema ← redness
(-) nevi ← moles
(-) lacerations

Psych:

(-) depression
(-) anxiety
(-) suicidal ideation
(-) homicidal ideation

Physical Exam (PE)

I almost always use a macro for this section that I made myself but referenced from other scribes more experienced than me. It automatically clicks (-) on important physical exam findings if all is normal.
Below are almost all the available options of things to click off in the physical exam section of the chart. I don’t touch 50% of the options below, only whatever is relevant in each patient’s chart. I gave a good amount of detail to let you familiarize yourself with the medical terms in the PE (NOT MEMORIZE!).

Basic ← usually limited overview page of all the systems

Const (Constitutional)

(-) no acute distress
□ ill-appearing
□ well-appearing
□ toxic-appearing
□ cachectic ← physical wasting with loss of weight and muscle mass due to disease

Eyes

□ PERRL ← pupils are equal, round, and reactive to light
□ EOMI ← extra ocular movement intact
(-) Conjunctival pallor

HENT

Head:
□ atraumatic □ normocephalic

Ears:
Tympanic membranes
□ translucent
(-) erythema (-) exudate (-) perforation
□ Nares patent
(-) turbinate swelling

Mouth:
Mucous membranes
□ moist
(-) lesions
Pharynx
□ uvula midline □ clear
(-) erythema (-) exudate
Tonsils
(-) erythema (-) edematous (-) exudate

Neck

□ neck supple
□ normal ROM (range of motion)
(-) lymphadenopathy (LAD)
(-) nuchal rigidity

Chest

□ chaperone present
(-) tenderness

Cardio

□ pulses normal
□ regular rate
□ regular rhythm
(-) murmurs (-) rubs (-) gallops
Radial and DP pulses #+
Cap refill < 2 or >2 seconds ← normally <2 sec

MSK

Upper:
Back:
Lower:
Lower legs
Left | Right
(-) edema (-) edema

Lungs

□ clear
□ breath sounds nl
(-) wheezing (-) rhonchi (-) rales

Abd

□ soft
□ bowel sounds normal in all 4 quadrants
(-) distended
(-) tenderness
(-) rebound
(-) guarding

Skin

□ warm
□ dry

GU
(often don’t go into this section due to the nature of the complaints I see, but lmk if you want to talk bout this part of the PE)

Neuro

(-) focal deficits
□ CN II-XII grossly intact
□ oriented x 3
Strength #/5 in upper and lower extremities bilaterally
□ Sensation intact
□ Coordination intact
□ Gait intact
Deep tendon reflex (DTR) #+/4 to biceps, triceps, patellar, brachioradialis, and achilles

Psych

□ mood nl
□ anxious
□ agitated

Assessment & Plan

Summary of the chief complaint is usually restated here.

Patient, a 73-year-old F, with a PMHx as noted above, comes to the ED presenting with productive cough x 1 week.

On exam, a&ox3, in NAD, neurologically intact. Pt is febrile. Lungs are CTAB and HRRR. Abd is soft and non-tender. Skin is warm and dry. Mucous membranes are moist—oropharyngeal erythema present.

In the note template you first use, the provider’s orders should auto-populate like below:

Will order:

[Imaging orders/Clinical lab test orders]

[Medication orders]

*If provider consults with another physician, put the time stamp (24 hr clock) and name of physician here. 

If you want you can also add any info the doctor states about their plan for the patient. Sometimes a differential diagnosis is explained here as well.

Please let me know if you have questions!

ED Course

(If working in the emergency department)

I usually use smartphrase .EKGtemplate if an EKG was ordered which auto-populates:

EKG
Heart Rate: [...] bpm
Heart Rhythm: [...] ← I write “NSR” or “normal sinus rhythm” if EKG is normal, if abnormal it may be either “Sinus Tachycardia” or “Sinus Bradycardia”
Interpretation: [...] ← I write “no acute changes” or “normal ECG” if the EKG/ECG was normal, but the provider may say something more specific to you.

Smartphrase .imagingtemplate if any imaging like X-rays or CT scans were ordered:

i.e.

X-ray chest AP portable
Interpretation:

Preliminary interpretation made by emergency provider. The radiologist will conduct an official read.

Imaging was ordered and reviewed.
[no results at this time] ← Refresh the note later to see if the radiologist’s interpretation has been completed, it will automatically pop up in this box if it has

Critical Care Documentation

“xx minutes of critical care”

(if the provider asks you to put a certain time of critical care given to the patient then you can input it, otherwise, I leave this section alone)

Heart Score

Leave for the provider to put in info unless they ask for you to do it

MDM (Medical Decision Making)

Usually formatted as checkboxes/box icons

         Clinical lab tests        

click |Ordered| |Reviewed|       

         Imaging

click |Ordered| |Reviewed|

         Medication

click |Ordered| |Reviewed|

□ independent visualization of images, tracings, or specimens

click |Stable|

Diagnosis

Never usually touch this section, the provider will put a diagnosis in themselves or leave it blank depending on their preferences

Disposition

Smartphrases used depending on how the patient will be handled:

.EDDischarge

.EDAdmit ← put the name of the medicine physician accepting pt

.EDObservation

.EDAMA ← Pt left AMA = against medical advice

Scribe Attestation:

Documented by [your name] acting as a scribe for [provider’s name].

Provider Attestation:

All medical records entrees made by the scribe were at my direction and personally dictated by me. I have reviewed the chart and agree that the record accurately reflects my personal performance of the history, physical exam, assessment, and plan.

[provider’s signature]