How to dictate an emergency department note

Before you start

Use a private environment and follow your workplace rules for recording and clinical documentation. If you capture a conversation with a patient, make sure any required notice and consent are handled before recording. DictaMed is a drafting tool; the treating clinician remains responsible for the final record.

Have the patient encounter and available results in front of you. If a result is still pending, say that it is pending. Do not fill the gap with an assumed normal result.

Dictate the encounter in a useful order

A note is easier to review when it follows the encounter from presentation to disposition. That order also helps you notice if the end of a long dictation is missing.

• State the presenting problem in one or two lines: the symptom or injury and why the patient came to ED. If arrival by ambulance matters, include it as context rather than as the complaint itself.
• Tell the history in time order, including what changed before arrival and any relevant negatives. Make clear whether a detail came from the patient, family, GP or paramedics when that affects its meaning.
• Add the relevant medical history, regular medicines, allergies and social circumstances. If something was not supplied, say “not documented” rather than turning the absence of information into “nil”.
• Describe what you observed and examined, using the measurements and units you recorded. Findings reported by a GP or paramedic belong in the earlier history, with attribution.
• Record which investigations were ordered, which results are available and which are pending. A test that is only planned should not appear as completed.
• Close with your working assessment, care given, response, outstanding actions, follow-up and disposition. Include safety advice when it was actually discussed.

Make clinical distinctions explicit

Small words can change a clinical statement. Say “possible”, “ruled out”, “pending”, “declined” and “not given” clearly, and check that they survive transcription. If someone gave a medicine before arrival, identify who gave it and where. Describe an investigation as completed only if it was done.

For a long case, a short closing recap can help: diagnosis or differential as stated, treatment and response, outstanding results, disposition, and the follow-up owner. It should not introduce facts that were not recorded earlier.

Review the transcript and the note

DictaMed shows a transcript to review before creating the clinical note. Check the beginning and ending, then correct recognition errors and add missing context. After note generation, compare the note with the transcript and encounter rather than treating polished wording as proof of accuracy.

Pay particular attention to age, laterality, negation, medicines and doses, allergies, observations, test results, assessment, treatment response and discharge instructions. Copy the reviewed note into your authorised clinical system; DictaMed is not the official patient record.