Admission note


Admission note

An admission note is written for any patient to be admitted to a hospital. 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), discharge 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.

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), 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 tests, 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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