Ask — the right questions

The can't-miss history and the exam findings that change risk.

complaint · history · exam

Chief complaint

common shown · search or pick a category · press /

Filter by specialty

History — what to ask

Mark all asked & negative attests you asked these and they were negative — use it only when that's true.

Physical exam — can't-miss checks

Mark all asked & negative attests you performed and documented these checks.

Rule out — the can't-miss

Name the killers, tie each to what lowers it, then stratify with a cited tool.

differential · risk · diagnosis

Differential & rule-outs

Risk tools

Data reviewed & interpreted

independent interpretation · records · historian · consult

I independently interpreted the ECG I independently reviewed imaging / another study External records reviewed History from an independent historian Discussed directly with a consultant

Working diagnosis

optional — the benign label, with the killers above documented as excluded

Name the benign endpoint you landed on. The note states the case is most consistent with it and that the can't-miss causes above were considered and judged unlikely.

Working diagnosis / conclusion

Protect & chart

Serial exams, disposition, and return precautions — the safety net, documented.

reassess · discharge

Reassessment & disposition

Document serial reassessment Acknowledge diagnostic uncertainty Shared decision-making (four-step: decision named · options & risks · patient values · mutual plan) Hospitalization was considered (high-risk management, even when discharged) Disposition rationale

Discharge instructions

Include discharge / return-precautions block

MDM block · paste into your note

Patient

tailors the questions & the note

Paste alongside your scribe’s note. Edits are kept. Synthetic example only.

Workup