Hospital Admission Note

OVERALL_INSTRUCTIONS

use relevant medical short forms like HTN, DM, Temp, RR, BUN, Cr, etc. The bracketed text in this template describes what a section should say when the encounter covered it. It is not a field that must be filled and not text to reproduce: write the section from what this visit actually established, and never leave square brackets in the letter. ID, CHIEF COMPLAINT, HISTORY OF PRESENT ILLNESS and ASSESSMENT AND PLAN always carry content. A short, informal or bedside encounter is still an encounter: a conversation about stopping an IV, sealing and locking a line, switching to thickened fluids, or testing a swallow is the substance of the letter, and so is a follow-up at which the patient reports nothing new. Name the patient and why they are being seen, what was discussed and found, and what was decided or is to happen next. Where the visit established that there are no new symptoms, say so — it is a finding, not an empty section. Leave out any section the encounter gave nothing for, rather than printing its heading with nothing under it. CXR, U/A, LABS, OTHER IMAGING STUDIES, the individual vital signs and each examination system appear only when the encounter actually reported them; where it did not, the heading does not appear at all. Never supply a vital sign, a laboratory value, an imaging finding or a normal examination finding the encounter did not state — omitting the heading is correct, inventing a value is not. The same applies to the numbered plan: number only the problems this encounter addressed. Do not carry an "F / E / N" item unless fluids, electrolytes or nutrition were actually discussed, and do not carry a code status item unless code status was discussed. Each plan item keeps what makes it actionable: the drug started, changed or stopped and the reason — including when it was stopped at the patient's own request and what they said prompted it; any dose still to be given; the contingency the clinician attached to it, such as switching to intravenous therapy if a large embolus is found; and the investigation or specialty follow-up arranged, with who it is with. Practical arrangements made at the bedside — a temporary pass to collect belongings, a line to be sealed and locked, a diet to be advanced — are plan items too. Give every problem the encounter addressed its own numbered item, and name each one: a second or third electrolyte deficiency that was discussed — phosphate as well as magnesium — is its own item, not folded into another. Keep the timing and the condition the clinician attached to each item in the words they used: the diet starts tonight, the fluids stop tomorrow if oral intake is adequate, the level is rechecked tomorrow, the pass is granted on condition the patient behaves responsibly. A plan item without its timing or its condition tells the receiving clinician less than the encounter established. Keep the negatives the clinician went looking for and the patient denied: no bleeding, no fever, chills or weight loss, no pain, no gastrointestinal symptoms, no tremor, no limb weakness, numbness or paraesthesia. A negative that was sought is part of the answer, not an absence of content. Keep what the encounter gave about timing, people and place: the day something started or is to happen, who else is involved in the patient's care, where the patient lives or is being transferred, and the family members present or spoken to. Keep the closing block — the signature, the physician's name and the site — as it appears in the template.

Chief Complaint

[Insert chief complaint in patient's own words]

Template

Date: [Insert Date] Referring Physician: [Insert Referring Physician Name] Dear Dr. [Last Name], ID: [Identify patient and reason for admission (working diagnosis). Include relevant past medical history.] CHIEF COMPLAINT: "[Insert chief complaint in patient's own words]" HISTORY OF PRESENT ILLNESS: [Begin by commenting on the patient's comorbid illnesses (diagnoses, severity, treatments) relevant to the current presentation. Then address the chronology of the patient's current illness, including pertinent review of systems positives. Mention relevant review of systems negatives.] PAST MEDICAL/SURGICAL HISTORY: [Insert list of past medical and surgical history, including dates and relevant recent results.] SOCIAL HISTORY: [Document social context – marital status, children, living situation, employment/retirement, activities, drug/alcohol use, sexual history, and other at-risk behaviors.] REVIEW OF SYSTEMS: [Insert pertinent positives and negatives as mentioned above, and any additional relevant findings.] PHYSICAL EXAMINATION: General: [Insert general appearance] Vitals: Temp [Insert] HR [Insert] RR [Insert] BP [Insert] SpO2 [Insert] HEENT: [Insert findings] CV: [Insert findings] Lungs: [Insert findings] Abdo: [Insert findings] Back: [Insert findings] Rectal: [Insert findings] MS: [Insert findings] Neuro: [Insert findings] CXR: [Insert chest x-ray findings] U/A: [Insert urinalysis findings] LABS: [Insert laboratory results, including past labs for baseline comparison if available.] OTHER IMAGING STUDIES: [Insert other imaging study results.] ASSESSMENT AND PLAN: [Start with a very brief summary of the case and relevant findings (physical exam, labs, imaging), then go into specific plans.] For example - In summary, this is a 72 yo gentleman with CAD/CHF/HTN/DM who presents with c/o SOB x 3 D and on exam found to have an S3 gallop and crackles 1/3 of the way up B, as well as 2+ LE edema B, and with labs significant for BUN/Cr of 42 : 1.4 and CXR with bilateral effusions not seen previously. Pt admitted for management of suspected CHF exacerbation. 1. [Diagnosis 1]: [Insert assessment and plan for diagnosis 1, including rationale and management steps.] 2. [Diagnosis 2]: [Insert assessment and plan for diagnosis 2, including rationale and management steps.] 3. [Diagnosis 3]: [Insert assessment and plan for diagnosis 3, including rationale and management steps.] 4. F / E / N: [Insert fluid/electrolyte/nutrition plan.] 5. [Insert miscellaneous recommendations.] 6. [Insert code status if available] Sincerely, [Insert Physician Name and Credentials] [Insert Contact Information]