Emergency Room Patient Charting Form
Use this Emergency Room Patient Charting Form to efficiently track key details of a patient encounter in the emergency department.
Patient Full Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Other
Date and Time of Encounter
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Chief Complaint / Reason for Visit
*
Vital Signs Summary
Triage Category
*
Please Select
Immediate (Red)
Urgent (Yellow)
Delayed (Green)
Minor (Blue)
Initial Assessment / Notes
Attending Clinician Name
*
Disposition / Next Steps
*
Please Select
Discharged
Admitted
Transferred
Observation
Other
Submit Chart
Should be Empty: