Thematic category | Description | Acronym key |
Patient identification | Name, age, gender Location within the department Relevant patient medical history Mode of arrival (eg, ambulance, family, self, police) | Entity |
Chief complaint | Working diagnosis Primary complaint/issue | Diagnosis |
Vital signs | Abnormal vital signs Overall clinical stability Anticipated resuscitative issues Code status | Vitals |
Investigations | Investigations ordered/completed/awaiting results | Investigations |
Care/treatment orders | Medications that have been given (home medications, emergent medications) Orders that have been given (fluids, nursing orders, etc) | Treatments |
Tasks | Actions undertaken Outstanding tasks to be completed Anticipated tasks | Actions |
Constraints to disposition | Patient home situation (supports, etc) Documents / forms completed or required to facilitate disposition Communication with family, other care providers | Logistics |
Services | Specialty services involved in patient care Status of consultant requests | Services |