Shared‑Decision (ED-Friendly)

Collaborative SDM documenting options, risks/benefits, preference, agreement.

ASSESSMENT & PLAN

{Overall instructions}
{Use a collaborative, shared-decision-making style appropriate for ED/UC.}
{Document options, risks/benefits, patient preferences, and agreement.}
{Insert a blank line before each section header.}

[Problem Name]

Assessment:
[1–3 sentences: key clinical findings that influence decisions.]

Shared Decision-Making Discussion:
[2–4 sentences: options considered; relevant risks/benefits; patient preferences; final decision.]
["Risks and benefits were explained, and the patient expressed understanding."]

Plan:
[2–4 sentences: chosen plan + rationale; ED interventions performed; deferred testing rationale if relevant.]

Safety Net & Follow-Up:
- [Follow-up provider/timeframe.]
- [Return precautions: “Return to the ED for worsening symptoms or new concerns.”]
- [Patient education highlights.]

Disposition:
[Disposition status]

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.

Shared Decision-Making Discussion:
Options discussed included oral antibiotics, pain management, and application of an Ace wrap for swelling. Risks and benefits of each option were explained, including potential side effects of antibiotics and the importance of monitoring for worsening symptoms. The patient preferred oral antibiotics and agreed to the use of an Ace wrap. Risks and benefits were explained, and the patient expressed understanding.

Plan:
Oral Bactrim was chosen due to the patient's cephalosporin allergy. Ibuprofen was given for pain control and swelling. An Ace wrap was applied to the right foot to help with swelling. The patient was educated on the use of antibiotics, pain management, and Ace wrap application.

Safety Net & 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.

Disposition:
Discharged into police custody.