Minimalist Micro-Checklist

Shortest possible, high-yield micro-sections.

ASSESSMENT & PLAN

{Overall instructions}
{Produce a concise Assessment & Plan using short, high-yield micro-sections.}
{Avoid storytelling or repeating full HPI details.}
{Insert a blank line before each section header.}

[Problem Name]

Assessment:
[1–2 sentences supporting the diagnosis; include only elements that change management.]

ED Interventions:
- [Medications administered in ED. Delete if none.]
- [Procedures performed. Delete if none.]
- [Diagnostics reviewed/ordered, if any. Delete if none.]

Discharge Medications:
- [Prescriptions with brief rationale. Delete if none.]

Follow-Up:
- [Provider/timeframe.]
- [Return precautions: “Return to the ED for worsening symptoms or new concerns.”]

Disposition:
[Disposition status]

Right Foot Swelling

Assessment:
Patient presents with right foot swelling, erythema, tenderness, and subjective fever for 2-3 days. Differential diagnosis includes cellulitis and other soft tissue infections.

ED Interventions:
- Oral Bactrim administered due to cephalosporin allergy.
- Ibuprofen given for pain control and swelling.
- Ace wrap applied to the right foot. CMS intact pre- and post-application.

Discharge Medications:
- Oral Bactrim prescribed for infection management.

Follow-Up:
- Follow up with primary care provider if concerns persist.
- Return to the ED for worsening symptoms or new concerns.

Disposition:
Discharged into police custody.