What is the format for writing ward notes after receiving a patient from the Emergency Room (ER)?

Format for Writing Ward Notes After Receiving a Patient from ER

Ward notes should follow a structured format that includes vital sign measurements, clinical deterioration assessment, and comprehensive discharge planning to ensure optimal patient outcomes and reduce morbidity and mortality. 1

Initial Assessment Section

Patient Identification

• Full name and medical record number
• Age and gender
• Date and time of admission
• Admitting physician
• Referring emergency physician

Chief Complaint and Source of Information

• Primary reason for admission in patient's own words
• Source of history (patient, family member, EMS, ER records)

History of Present Illness

• Chronological narrative of the current illness
• Onset, duration, and progression of symptoms
• Relevant ER interventions and patient's response
• ER diagnostic test results and their significance

Vital Signs

• Complete set of vital signs from ER and upon ward arrival
• Temperature, heart rate, respiratory rate, blood pressure, oxygen saturation
• Pain score and mental status assessment 1

Physical Examination

• Focused examination based on presenting complaint
• Systematic review of relevant organ systems
• Documentation of any abnormal findings
• Comparison with ER findings to note any changes

Assessment and Plan Section

Problem List

• Numbered list of active problems in order of priority
• Primary diagnosis and differential diagnoses
• Each problem should have corresponding assessment and plan

Assessment

• Clinical reasoning and interpretation of findings
• Severity assessment of condition
• Risk stratification for clinical deterioration 1

Plan

• Diagnostic plan: tests ordered or pending
• Therapeutic plan: medications, procedures, consultations
• Monitoring plan: frequency of vital signs, specific parameters
• Discharge planning: initiated early in admission 2

Special Considerations

Medication Reconciliation

• Complete list of home medications with doses and schedules
• New medications started in ER with indications
• Medication changes or discontinuations with rationale
• Special attention to high-risk medications in geriatric patients 1

Clinical Deterioration Prevention

• Early warning criteria for RRT/MET activation
• Specific vital sign parameters requiring escalation
• Documentation of patient/family education on when to alert staff 1

Discharge Planning Elements

• Begin discharge planning at admission
• Equipment needs and community support services required
• Follow-up appointments needed
• Interdisciplinary team involvement (PT, OT, social work) 2

Documentation Best Practices

Communication Elements

• Document verbal handoff from ER physician
• Note any pending results or interventions
• Document discussions with patient/family about care plan
• Include contact information for key providers 1

Clarity and Accessibility

• Use clear, concise language avoiding medical jargon
• Organize information in a standardized format
• Ensure legibility if handwritten or proper formatting if electronic
• Use bullet points for clarity when appropriate 3

Common Pitfalls to Avoid

1. Failing to document clinical deterioration criteria and escalation plans
2. Omitting medication reconciliation or incomplete medication lists
3. Delaying discharge planning until later in hospitalization
4. Not documenting patient education provided in ER
5. Failing to coordinate with interdisciplinary team members 2

Ward Note Template Example

Date/Time:
Patient Name:                      MRN:                Age/Gender:
Admitted From: Emergency Department
Admitting Diagnosis:
Admitting Physician:               ER Physician:

SOURCE OF INFORMATION: [Patient, family, ER records]

CHIEF COMPLAINT: "[Patient's words]"

HISTORY OF PRESENT ILLNESS:
[Chronological narrative]
[ER course summary]

PAST MEDICAL HISTORY:
[Relevant conditions]

HOME MEDICATIONS:
[Complete list with doses]

ALLERGIES:
[Medications and reactions]

SOCIAL HISTORY:
[Relevant social factors]

VITAL SIGNS:
ER arrival: T___ HR___ RR___ BP___ O2Sat___
Ward arrival: T___ HR___ RR___ BP___ O2Sat___
Pain score: ___/10
Mental status: [Alert/Confused/Drowsy/Unresponsive]

PHYSICAL EXAMINATION:
[Focused examination findings]

LABORATORY/DIAGNOSTIC RESULTS:
[Significant findings]
[Pending studies]

ASSESSMENT:
Problem #1: [Diagnosis/Problem]
- [Clinical reasoning]
- [Severity assessment]

PLAN:
Problem #1:
- Diagnostic: [Tests ordered]
- Therapeutic: [Medications, interventions]
- Monitoring: [Parameters, frequency]
- Disposition: [Discharge planning initiated]

CLINICAL DETERIORATION CRITERIA:
[Specific parameters requiring escalation]

INTERDISCIPLINARY TEAM INVOLVEMENT:
[Consultations requested]
[PT/OT/SW needs]

Signature: _______________
Provider Name/Credentials
Date/Time: _______________