EM TD2

Performing and documenting focused histories and physical exams, and providing preliminary management of cardinal emergency department presentations

epa_guide_emergency_med_v2_2024, page 3

Key features: collection and synthesis of key information to guide the initial management of cardinal presentations in the emergency department. Complete documentation of the clinical encounter in the medical record is also a key feature.

• The differential diagnosis and management plan are not expected to be complete or fully accurate.
• Cases should be reviewed with the supervisor before finalization or communication with the patient or family to ensure appropriate feedback is integrated into documentation and patient care accurately

Assessment plan

• Form 1
• Clinical presentation
  • Chest pain
  • Shortness of breath
  • Abdominal pain
  • Minor trauma
• observation: direct and indirect
  • by supervising physician or resident in C - Core of Discipline or TP - Transition to Practice.
  • on case discussion, review of the completed medical record
• collect 20 observations of achievement
  • at least 5 observations (including 2 direct) of each cp listed