Admission note

An admission note is written for patients to be admitted to a hospital. It is possible for multiple admission notes to be written for a single patient.

Purpose

Admission notes are used by healthcare payors to determine billing; doctors use them to record a patient's baseline status and may write additional on-service notes, progress notes (SOAP notes), preoperative notes, operative notes, postoperative notes, procedure notes, delivery notes, postpartum notes, and discharge notes. These notes constitute a large part of the medical record. Medical students often develop their clinical reasoning skills by writing admission notes.

Components

An admission note may sometimes be incorrectly referred to as an HPI (history of present illness) or H and P (history and physical), which include only portions of an admission note. An admission note includes:

• chief complaint
• history of present illness, including a separate paragraph summarizing related history
• review of symptoms
• allergies, including drug allergies (including antigens and responses)
• past medical history
• past surgical history
• family history, including health of siblings, parents, spouse, and children, living and dead
• social history
• medications
• physical exam
• labs
• diagnostics studies
• assessment
• plan

Outline

Not every admission note explicitly discusses every item listed below, however, the ideal admission note would include:

Header

• Patient identifying information (maybe located separately)
  • name
  • ID number
  • chart number
  • room number
  • date of birth
  • attending physician
  • sex
  • admission date
• Date
• Time
• Service

Chief complaint (CC)

Main article: Chief complaint

Typically one sentence including

• age
• race
• sex
• presenting complaint
• example: "34 yo white male with right-sided weakness and slurred speech."

History of present illness (HPI)

Main article: History of the present illness

• statement of health status
• detailed description of chief complaint
• positive and negative symptoms related to the chief complaint based on the differential diagnosis the health care provider has developed.
• emergency actions taken and patient responses if relevant

Allergies

Main article: Allergy

• first antigen and response
• second antigen and response
• etc

Family history (FmHx)

Main article: Family history (medicine)

Health or cause of death for:

• Parents
• Siblings
• Children
• Spouse

Social History (SocHx)

Main article: Social history (medicine)

In medicine, a social history is a portion of the admission note addressing familial, occupational, and recreational aspects of the patient's personal life that have the potential to be clinically significant.

Medications

Main article: Pharmaceutical drug

• for each: generic name - amount - rate
• medications on arrival (aspirin, Goody's medicated powder, herbal remedies, prescriptions, etc)
• medications on transfer

Physical exam

Main article: Physical examination

Physical examination or clinical examination is the process by which a health care provider investigates the body of a patient for signs of disease.

Review of systems (ROS)

Main article: Review of systems

• General
• Head
• Eyes
• Ears
• Nose and sinuses
• Throat, mouth, and neck
• Breasts
• Cardiovascular system
• Respiratory system
• Gastrointestinal system
• Urinary system
• Genital system
• Vascular system
• Musculoskeletal system
• Nervous system
• Psychiatric
• Hematologic system
• Endocrine system

Labs

eg: electrolytes, arterial blood gases, liver function tests, etc

Diagnostics

eg: EKG, CXR, CT, MRI

Assessment and Plan

Main article: Assessment and plan

Assessment includes a discussion of the differential diagnosis and supporting history and exam findings.

References

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