SAMPLE RECORDSaint Thomas ER
Emergency Department Encounter
Patient:
DOB:
Date of Service:Apr 15, 2026
MRN:
Arrival:Private vehicle
Triage:Level 3 · Urgent
CHIEF COMPLAINT
Right Ankle pain following a motor vehicle collision.
TRIAGE VITALS
BP 147/81 · HR 83 · RR 17 · Temp 98.0°F · SpO₂ 99% · Pain 6/10
HISTORY OF PRESENT ILLNESS
Fall on apartment stairway; right ankle fracture confirmed on X-ray.
DIAGNOSES
• Right ankle fracture (S82.6)
DISPOSITION
• Ankle X-ray
• Splint applied
• Orthopedic referral, non-weight-bearing
Electronically signed by · Emergency PhysicianPage 7 of 22
Representative emergency department encounter from this sample case. The highlighted text is the fact Arbor extracted and linked to Saint Thomas ER Records, page 7.