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Emergency Medicine · Templates

Emergency H&P template

Built for emergency and urgent episodic care where the note must move quickly from presentation to medical decision-making and disposition.

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Template content

Copy or download, then paste into Wavo under My Templates.

Emergency Department H&P

Chief Complaint
- Patient's stated reason for visit.

HPI
- Onset, severity, associated symptoms, pertinent negatives, and context.
- Timeline of care before arrival (EMS, outside facility, home treatments) if relevant.

History
- PMH, medications, allergies, and relevant social history as available.
- Last menstrual period / pregnancy status when clinically relevant.

Exam
- Vital signs including triage and repeat vitals as performed.
- Focused exam findings by system as performed; critical negatives documented.

ED Course / MDM
- Differential diagnosis and clinical reasoning.
- Data reviewed (labs, imaging, ECG, prior records).
- Reevaluations, response to therapy, procedures, and consultations.
- Risk stratification and shared decision-making as applicable.

Disposition
- Discharge, admission, observation, or transfer with clinical rationale.
- Medications, prescriptions, work/activity guidance, return precautions, and follow-up.

When to use this template

What makes the structure useful, and which visits it fits best.

Why this template works

Structural advantages for real documentation

Best for

Visit types and clinicians who use this format

  • Prioritizes MDM and disposition—the sections ED notes live or die on.
  • Keeps reevaluation and procedures easy to capture.
  • Good organization starter template for ED groups.
  • Supports teaching-service documentation without forcing ambulatory SOAP.
  • 1Emergency department encounters
  • 2Urgent care higher-acuity visits
  • 3ED teaching services

Example output shape

Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.

Chief Complaint
Left-sided chest pain for 2 hours.

HPI
57-year-old with hypertension and hyperlipidemia reports pressure-like left chest pain radiating to left arm, onset at rest, associated with diaphoresis and mild dyspnea. Pain 7/10 at onset, now 4/10 after EMS nitroglycerin. Denies syncope, palpitations, fever, or cough. No prior MI.

Exam
Triage: BP 158/92, HR 96, SpO2 98% RA, pain 4/10. Appears uncomfortable but not in distress. Lungs clear; heart regular without murmur; abdomen soft; no calf swelling. ECG: sinus rhythm, no acute ST elevation; nonspecific T-wave changes laterally.

ED Course / MDM
Differential includes ACS, PE (Wells low), aortic syndrome (less likely—no tearing/back pain, equal pulses), and musculoskeletal pain. Troponin ×2 negative. CXR without acute process. Aspirin given; cardiology consulted. Pain resolved with additional nitroglycerin.

Disposition
Admit to telemetry for rule-out ACS / further risk stratification. NPO pending morning stress pathway per cardiology. Patient agrees with plan.

How Wavo automates this

What the product actually does with your template.

1. Add the template

Paste this content into My Templates, or start from a specialty-generated template and edit the sections.

2. Record or dictate

Capture the encounter with ambient recording or dictation. Wavo structures the note using your template.

3. Review and sign

Edit with Smart Transform if needed, then export or copy into your EHR. You stay responsible for the final note.

Put this template to work on your next visit

Start free, paste the template, and see how Wavo documents in your structure.

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