Emergency Room Record

Doctor’s Note

Patient’s Name: Age: Gender:

Address: Date:
Condition At Arrival: Time of Arrival: Time of Departure:

Chief Complaint:

Past Medical & Surgical History:

History:

Drug History:

Drug Allergies:

No

Yes:
Vital Signs:

Temperature:

Pulse:

Respiratory Rate:

O2 Sat.

Actions Taken: Recommendations:

Doctor’s Name: Date & Time: