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Emergency Medicine

A&E and emergency documentation templates and standards.

Documentation Overview

Emergency documentation must be rapid, structured and legible. Time-critical decisions must be documented contemporaneously with clear clinical reasoning. The emergency record often forms the cornerstone of subsequent medicolegal review.

Key Documentation Standards

  • Triage category and time documented on arrival
  • Time of clinician assessment documented
  • ABCDE assessment documented for sick patients
  • Pain score on arrival and post-analgesia
  • Mechanism of injury for trauma
  • Safeguarding concerns documented appropriately
  • Discharge with clear safety-netting instructions documented

Common Documentation Scenarios

  • Trauma — ATLS-structured primary and secondary survey
  • Chest pain — presenting features, ECG findings, troponin results, disposition
  • Sepsis — time of recognition, Sepsis 6 bundle documented
  • Paediatric emergency — weight-based documentation, child-specific parameters
  • Mental health — mental state examination, capacity assessment, risk documentation
  • Minor injuries — mechanism, examination, imaging, discharge advice

Relevant Templates

Quick Reference
EMERGENCY DOCUMENTATION CHECKLIST
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INITIAL ASSESSMENT
□ Triage time and category
□ Presenting complaint
□ Vital signs on arrival
□ Pain score

CLERKING
□ Time clinician assessed patient
□ History (including mechanism)
□ Examination findings
□ GCS if altered consciousness
□ Investigations ordered

SICK PATIENT — ABCDE
□ Airway: patency
□ Breathing: rate, effort, SpO2
□ Circulation: HR, BP, CRT
□ Disability: GCS, BM, pupils
□ Exposure: temperature, inspection

SEPSIS
□ Time of recognition documented
□ Sepsis 6 bundle completion times

DISCHARGE
□ Diagnosis / working diagnosis
□ Treatment given
□ Safety-netting advice documented
□ Follow-up instructions
□ Return instructions ("if worried...")
Specialty-specific: Always refer to your hospital's specialty-specific documentation policies and national guidelines.