Checklist / Protocol-Driven

Strict ED/UC checklist: Diagnostics → Procedures → Meds → Consults → Disposition → Follow‑Up.

ASSESSMENT & PLAN

{Overall instructions}
{Use a strict checklist-style structure appropriate for ED and urgent care.}
{Always print each major section in this order: Diagnostics, Procedures, Medications, Consultations, Disposition, Follow-Up.}
{Delete individual lines if no content is available.}
{Insert a blank line before each section header.}

[Problem Name]

Assessment:
[Concise 1–3 sentence impression.]

Diagnostics:
- [Labs ordered/reviewed with brief interpretation. Delete line if none.]
- [Imaging ordered/reviewed with brief interpretation. Delete line if none.]
- [Other diagnostic tests. Delete line if none.]

Procedures:
- [Procedure performed. Delete line if none.]
- [If splint/wrap: "Splint check performed. CMS intact pre- and post-application."]

Medications:
- [ED medications administered, with rationale. Delete line if none.]
- [Discharge prescriptions provided, with rationale. Delete line if none.]

Consultations:
- [Consultant + actionable recommendation. Delete line if none.]

Disposition:
[Disposition status]

Follow-Up:
- [Follow-up provider/timeframe. Delete line if none.]
- [Return precautions: “Return to the ED for worsening symptoms or new concerns.” unless otherwise specified.]
- [Patient education provided. Delete line if none.]

Right Foot Swelling

Assessment:
The patient presents with right foot swelling, erythema, tenderness, and a subjective fever, which began 2-3 days ago. Differential diagnosis includes cellulitis and other soft tissue infections.

Diagnostics:
- None

Procedures:
- Ace wrap applied to the right foot. CMS intact pre- and post-application.

Medications:
- Oral Bactrim administered due to cephalosporin allergy.
- Ibuprofen given for pain control and swelling.

Consultations:
- None

Disposition:
Discharged into police custody.

Follow-Up:
- Follow up with primary care provider if concerns persist.
- Return to the ED for worsening symptoms or new concerns.
- Patient education provided on antibiotics, pain management, and Ace wrap use.