MSE template

w/ pertinent PMH/PSH of
Pertinent (to CC) vital sign and exam abnormalities:
Ddx includes but not limited to:
Awaiting bed
Of note, this is a limited medical screening exam. The history/exam is insufficient for compelte eval in the ED given the limitations of time and the intention of this exam is to determine initial diagnostics to expedite care by AED/RME team assuming care of patient. Further history and exam to be obtained per protocol by AED/RME team that subsequent to this examination assumes care of patient. As such, there is recognition that aspects of the history or exam may be incomplete given time limitations and inability to derobe nor keep patient on monitor for full evaluation. Patient educated that this is not a complete evaluation and the necessity of staying for full evaluation by AED/RME team.

Leave a Comment