The short answer
In an Emergency note, the Chief Complaint says why the patient came. The history then follows events in time order, leading to the current examination, investigation results, assessment and plan. Attribute earlier findings to the person who made them, and do not fill an empty heading with an unsupported clinical fact.
Complaint and history
The Chief Complaint usually needs only a line or two. In the workplace example, “Tachycardia and distress following a workplace argument” tells the reader why the patient came. Arrival by ambulance is useful context for the history, but it does not explain the complaint on its own.
The History of Present Illness should carry the reader from the first symptom through any changes, assessment or treatment before arrival, and transport to ED. If a GP or paramedic made an observation, say so here. The treating doctor’s own findings belong in the examination.
Background, examination and investigations
DictaMed’s Emergency workflow includes Medical History, Medications and Allergies; Family History; Social History; Immunisations; Examination; and Investigations, Plan and Results. Include only information relevant and supported by the source. “Not stated” and “nil” mean different things.
Examination holds the treating clinician’s observations and findings. Investigation records which tests were ordered, what has resulted and what remains pending. A plan for thyroid testing must not be written as a normal thyroid result.
Assessment and plan
State the clinician’s working impression at the level of certainty actually expressed. Then list treatment given, response, outstanding results, follow-up, advice and disposition as documented. Do not repeat the entire history or move management into the chief complaint.
A complete Emergency note helps a receiving clinician understand what was found and what remains to be done. Review the output for omitted negatives, changed numbers and unsupported conclusions before transfer.
Common questions
Should a GP’s findings appear in Examination?
Usually describe them in the history with attribution. Reserve the treating doctor’s Examination for that doctor’s current findings.
Do all headings need a “nil” entry?
No. Do not turn missing source information into a negative clinical fact.
Sources and product details
- Medical Board of Australia — Good medical practice
- NSW Agency for Clinical Innovation — ED models of care
These guides describe DictaMed’s current workflow and general documentation principles. Follow your workplace policy and use clinical judgement for each patient.