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.

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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 systems
• 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.