Admission note on arvau

Wikipedia / Admission note

An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.

Purpose

Admission notes document the reasons why a patient is being admitted for inpatient care to a hospital or other facility, the patient's baseline status, and the initial instructions for that patient's care. Health care professionals 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. The traditional, rational definition of being admitted usually involves spending an overnight in the hospital. This definition is sometimes stretched in the U.S. medical billing industry, where hospital corporations may blur the definitions of "admission" and "observation" because of reimbursement rules under which healthcare payors pay less for the care if an "admission" was involved.

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 can include the following sections:

Outline

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

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

Allergies

first antigen and response
second antigen and response
etc.

Past medical history (PMHx)

List of the patient's on-going medical problems. Chronic problems should be addressed as to whether or not they are well controlled or uncontrolled. Include dates of pertinent items.

Past surgical history (PSurgHx, PSxHx)

List of surgeries in the past with dates of pertinent items.

Family history (FmHx)

Health or cause of death for:

Parents
Siblings
Children
Spouse

Social history (SocHx)

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

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

Review of systems (ROS)

Physical exam

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

Labs

e.g.: electrolytes, arterial blood gases, liver function tests, etc.

Diagnostics

e.g.: EKG, CXR, CT, MRI

Assessment and plan

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