Complex Adult Emergency Medicine Note Template (Epic & Generic)

Writing notes in residency and beyond is something that no one teaches you. You’re thrown into the mix and you have to learn and adapt and figure it out yourself. This template is the result of years of learning how to write better notes each time, and includes facets from other people’s note templates, all compiled into one that I’m finally satisfied with.

It took me months to finalize my template for a generic complex adult presenting to the emergency department. This note has gone through many iterations, and will likely continue to change/evolve.

All updates will be available via the same Notion link that you get from this.

IMPORTANT: You can adapt this to make it truly yours — it’s fully customizable. Make sure you don’t include anything that you don’t explicitly look at or think about. Be very careful with templates in medicine. Please make sure you edit ALL relevant fields for each patient, because it’s easy to make mistakes and leave in an “A&Ox4” physical exam for a patient who is intubated and sedated.

The SmartPhrases are helpful in Epic but don't cross over to most other EMRs, so I included a generic one as well. For a limited time I also included my basic "visual" physical exam dot phrase that you can use for those non-complex ED cases that you're inevitably going to see.