Emergency Room Doctor’s Note with Examples: Templates & Time-Saving AI Tools

Updated on: July 2, 2025

In the chaos of the emergency room, speed and accuracy save lives. But for every patient admitted, treated, or discharged, ER physicians must generate clear, timely, and legally sound documentation.

A well-structured emergency room doctor’s note serves as:

• A clinical record for ongoing care

• A communication tool for the care team

• A legal document for liability protection

• A source of truth for billing and coding

Unfortunately, in many busy ER settings, providers spend 1–3 hours per shift catching up on documentation. That’s time lost to screen fatigue — and not enough face time with patients.

Enter Docscrib — an AI medical scribe that listens during encounters, writes accurate SOAP notes in real time, and integrates directly into your EHR.

⚡ Whether you’re managing trauma, chest pain, or psychiatric crises, Docscrib captures the clinical story while you stay focused on care.

What Should an ER Doctor’s Note Include?

A high-quality emergency room note includes the following components:

1. Chief Complaint (CC)

2. History of Present Illness (HPI)

3. Past Medical History / Allergies / Medications

4. Physical Examination Findings

5. Diagnostic Testing & Results

6. Medical Decision Making (MDM)

7. Assessment & Plan

8. Disposition (Admit, Discharge, Transfer)

9. Follow-Up Instructions

10. Attending/Resident Sign-off (if applicable)

Using a standard structure like SOAP (Subjective, Objective, Assessment, Plan) helps ER doctors maintain consistency and clarity under pressure.

Emergency Room Doctor’s Note Template (SOAP Format)

Patient Name: John Doe
Date/Time: 07/01/2025, 3:30 PM
Provider: Dr. Sarah Lee
Location: Emergency Department, Room 12
MRN: 000987654

S – Subjective (HPI)

45-year-old male presents with acute onset chest pain radiating to the left arm, started 1 hour ago while mowing the lawn. Describes the pain as “pressure-like,” 8/10 in intensity. Denies shortness of breath but reports diaphoresis and nausea. No prior history of similar episodes. No known cardiac disease.

O – Objective

• Vitals: BP 142/90, HR 102 bpm, RR 20, Temp 98.7°F, SpO₂ 96% RA

• General: Alert, anxious

• Cardio: Tachycardic, no murmurs, no JVD

• Respiratory: Clear to auscultation bilaterally

• GI: Soft, nontender

• EKG: ST elevations in leads II, III, aVF

• Troponin I: 0.46 (elevated)

• CXR: No acute pulmonary findings

A – Assessment

ST-elevation myocardial infarction (STEMI) – Inferior wall
Hypertension
Hyperlipidemia (history)

P – Plan

• Activate cath lab

• Administer aspirin 325 mg PO

• Start IV nitroglycerin drip

• Notify cardiology

• Transfer to ICU post-intervention

Disposition

Admitted to Cardiac ICU
Family updated. Informed consent obtained.

More Emergency Room Doctor’s Note Examples

🧠 Example 1: Head Injury from Fall (Discharged)

S: 68-year-old female fell in the bathroom, hit occipital region. Denies LOC or vomiting. Complains of mild headache. No anticoagulants.
O: Normal neuro exam, no scalp laceration, negative head CT
A: Minor head trauma, low-risk for ICH
P: Discharged with head injury instructions, advised to return for worsening symptoms

🫁 Example 2: Pediatric Asthma Exacerbation (Admitted)

S: 8-year-old male with known asthma presents with SOB, wheezing, and accessory muscle use
O: HR 120, RR 32, SpO₂ 91% on RA
A: Acute moderate asthma exacerbation
P: Albuterol neb x3, IV steroids, oxygen therapy. Admitted to pediatric ward.

Why ER Notes Matter for Billing & Compliance

Poorly written notes can lead to:

• Denied insurance claims

• Poor communication during handoff

• Legal risk in adverse events

• Incomplete documentation of interventions (meds, procedures, consent)

That’s why ER documentation needs to be:

✅ Structured
✅ Time-stamped
✅ Procedure- and medication-specific
✅ Legally defensible

Save Time with Docscrib: Your AI Scribe for the ER

Docscrib is an AI-powered medical scribe that listens securely during ER patient interactions and auto-generates structured notes.

🔹 Built for Speed

• Finish notes during the patient encounter

• Eliminate after-hours charting

🔹 Built for Accuracy

• Understands emergency medicine terminology

• Formats notes to SOAP or departmental preference

🔹 Built for Compliance

• HIPAA-compliant and SOC 2 certified

• Secure, encrypted, and fully editable

Docscrib vs. Manual ER Charting

🧑‍⚕️ “Docscrib helps me close notes during the shift. For the first time in 10 years, I leave on time.”
— Dr. Allen C., ER Physician, Denver Health

FAQs

Can Docscrib be used in trauma codes and critical care?

Yes. Docscrib adapts to high-acuity encounters and can document critical procedures (intubation, chest tube, CPR) in real-time.

Is Docscrib compatible with Epic/Cerner?

Yes. Docscrib works via integration or seamless copy-paste with all major EHRs, including Epic, Cerner, Meditech, and Athena.

Can residents and NPs use Docscrib in academic EDs?

Absolutely. Docscrib can be configured per user and supports teaching environments.

How to Get Started

🚀 Want to chart less and focus more on emergency care?

1. Visit docscrib.com

2. Book a live demo tailored to ER workflows

3. Start your free trial and go live in days

👉 Book Your ER Docscrib Demo Now →

Final Thoughts: Docscrib Brings Order to ER Documentation

Emergency medicine is unpredictable — but your documentation doesn’t have to be.

With Docscrib’s AI medical scribe:

• You write fewer notes

• You chart more accurately

• You reclaim your nights

💡 Structured notes. Faster shifts. Better care. That’s the Docscrib difference.

👉 Try Docscrib – The AI Scribe for Emergency Medicine