EMERGCITY - Emergency Medicine Physician Forum

Full Version: Parts of the ED Medical Record
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Chief Complaint (CC), History of Present Illness (HPI), Review of Systems (ROS), Past Medical History (PMHx), Past Surgical Hx (PSHx), Social History (SHx), Family History (FHx), Physical Exam (PE), Vital Signs (VS), Lab and Imaging Results, Reassessments, Differential Diagnosis (DDx), ED Course, Clinical Decision Making, Critical Care Statement, Diagnosis (Dx), Follow-Up, Prescriptions (Rx), Discharge Instructions