Hospital Admission Note (letter)

OVERALL_INSTRUCTIONS

use relevant medical short forms like HTN, DM, Temp, RR, BUN, Cr, etc.

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]