- Admission note
An admission note is written for any
patient to be admitted to a hospital. Admission notes are used byhealthcare payors to determine billing; doctors use them to record a patient's baseline status and may write additionalon-service note s,progress note s (SOAP note s),discharge note s,preoperative note s,operative note s,postoperative note s,procedure note s,delivery note s,postpartum note s, anddischarge note s. These notes constitute a large part of themedical record . Medical students often develop theirclinical reasoning skills by writing admission notes.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
* planOutline
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), 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)
** 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
* Review of Systems (ROS)
** 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
* Allergies
** first antigen and response
** second antigen and response
** etc
* Past Medical History (PMHx)
* Past Surgical History (PSurgHx)
* Family History (FmHx): health or cause of death for
** Parents
** Siblings
** Children
** Spouse
* Social History (SocHx)
** Alcohol
** Tobacco
** illicit drugs
** occupation
** sexual preference (increased risk of various infections among prostitutes, johns, and males engaging in anal-receptive intercourse)
** prison (especially if tuberculosis needs to be ruled out)
* Medications
** for each: generic name - amount - rate
** medications on arrival (aspirin , Goody's medicated powder,herbal remedies ,prescriptions , etc)
** medications on transfer
* Physical Exam
* Review of Systems (ROS)
** 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 test s, etc
* Diagnostics, eg:EKG ,CXR ,CT ,MRI
* Assessment and Plan
** Assessment includes a discussion of the differential diagnosis and supporting history and exam findings.
** The plan is typically broken out by problem or system. Each problem should include:
*** brief summary of the problem, perhaps including what has been done thus far
*** orders for medications, labs, studies, procedures and surgeries to address the problem.
** problems are commonly derived from
*** chief complaint
*** history of present illness
*** review of systems rarely, these should have been picked up and incorporated as new chief complaints during the interview
*** physical exam rarely, these should have been picked up and incorporated as new chief complaints during the exam
*** social history, including counseling for smoking, alcohol, and illicit drug use
*** family history
*** medications may indicate problems that need to be addressed in the treatment of the other problems, such as dyslipidemia controlled with a statin.
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