Emergency Medicine Guidelines

Initial Evaluation

A focused medical assessment should be directed by the patient's presenting complaint, rather than routine comprehensive testing for all patients, as recommended by the American College of Emergency Physicians 1
A focused history should be obtained, including the timing of symptom onset and medical history, medication, and drug use information, with a baseline severity score performed as part of the initial evaluation 2, 3
High-risk patients, such as the elderly, those with substance abuse, or preexisting medical complaints, should be rapidly identified for immediate intervention 1

For alert, cooperative patients, a complete focused assessment should be based on the presenting complaint, while for patients with altered mental status, collateral history should be obtained from family, EMS, or witnesses 1, 3
For critically ill patients, immediate life-threatening issues should be prioritized while gathering essential history in parallel, with advance notice provided to the ED of potential critical patients to initiate pathways and alert consulting services 3

Routine laboratory testing for all patients has a low yield and should be avoided, with diagnostic evaluation directed by the history and physical examination findings, as recommended by the American College of Emergency Physicians 1
For psychiatric patients with normal vital signs and noncontributory history/physical exam, routine laboratory testing is unnecessary 1

Clear and legible documentation should be ensured, avoiding "do not use" abbreviations, with laboratory, radiologic, and allied health testing results incorporated appropriately 4
The American College of Emergency Physicians recommends documenting clinically relevant aspects of the patient encounter, including chief complaint, duration, and pertinent positive and negative findings, with the American Academy of Pediatrics suggesting documentation of factors contributing to decision-making complexity 5, 4
Documentation should clearly articulate the thought process, including differential diagnoses, rationale for diagnostic tests, and interpretation of results, with regular review for completeness and accuracy, as recommended by the American College of Emergency Physicians 6, 4
The use of standardized templates and decision support tools, such as the SOFA score for sepsis risk assessment, can improve documentation completeness and facilitate shared decision-making, as suggested by the Society of Critical Care Medicine and the American College of Emergency Physicians 7, 4