PARADISE REGIONAL MEDICAL CENTER
MSE Tracking Board
SIMULATED TRAINING ENVIRONMENT
Assigned Physician
Dr. John Smith
Dr. John Smith
ACTIVE MEDICAL SCREENING EXAM
ELAPSED
00:00
MSE in progress
The patient was seen by me for a brief assessment prior to a complete
Emergency Department visit. The purpose of this initial assessment is
to provide a Medical Screening Exam (MSE), establish the reason for this
patient's visit, and initiate care and workup prior to their full
evaluation by one of the ED Physicians/APCs. Additional orders and
further management will be at the discretion of the Emergency Medicine
Providers upon room placement. Please refer to subsequent ED notes for
the full ED H&P and comprehensive assessment and ultimate disposition
of the patient.
C/C:
Focused exam:
Constitutional: No apparent distress.
Skin: Warm, dry.
HENT: Normocephalic, atraumatic.
Pulmonary: No accessory muscle use or stridor.
Cardiovascular: Regular rate, rhythm.
Gastrointestinal: Non-distended, soft.
Musculoskeletal:
Extremities are nontender and have no gross deformity.
Neurologic:
Alert. Moves all extremities without motor or sensory deficit.
Psychiatric: Normal mood and affect.
MSE Decision
Based on the triage information, brief history and focused examination:
Required Escalation Documentation
Charge Nurse:
Supervising Physician:
Provider:
MSE started:
MSE completed: —
Elapsed time: —
MSE completed: —
Elapsed time: —