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'''Admission Note''' is a pivotal part of the [[medical record]] that chronicles the [[patient]]'s [[medical state|status]] encompassing [[medical history|history]] and [[physical examination|physical examination outcomes]]. This note elucidates the rationale behind the patient's [[inpatient care]] admission to a medical facility and lays down preliminary care directives.<ref name="urlGeneral Info">{{cite web| url= http://students.washington.edu/aomega/geninfo.shtml| title= General Info| accessdate= 2009-04-03| archiveurl= https://web.archive.org/web/20090312030707/http://students.washington.edu/aomega/geninfo.shtml| archivedate= 12 March 2009| url-status= dead| df= dmy-all}}</ref>
'''Admission Note''' is a crucial component of the [[medical record]] that documents a [[patient]]'s [[medical history]], [[physical examination]] findings, and the rationale for their [[inpatient care]] admission. This note establishes the foundation for the patient's treatment plan and serves as a reference for healthcare providers throughout the hospital stay.


==Purpose==
== Purpose ==
The quintessential role of the admission note is to delineate the reasoning behind a [[patient]]'s [[inpatient care]] admission, detailing their baseline health metrics and initial care recommendations. [[Health care professional]]s utilize these notes to document a patient's foundational health state. Subsequent notes, such as [[on-service note]]s, [[progress note]]s ([[SOAP note]]s), [[preoperative note]]s, [[operative note]]s, [[postoperative note]]s, [[procedure note]]s, [[delivery note]]s, [[postpartum note]]s, and [[discharge note]]s, might follow. The entirety of these notes forms a significant portion of the [[medical record]]. Budding medical practitioners often refine their [[clinical reasoning skills]] crafting these admission notes. Conventionally, an "admission" denotes an overnight hospital stay. However, in the realm of the [[Medical billing (United States)|U.S. medical billing]], this definition might undergo some modifications due to reimbursement paradigms. These paradigms might influence the distinction between "admission" and "observation", potentially leading to reduced reimbursement rates for the involved "admissions".<ref name="ColumbusDispatch_2011-02-14">{{Citation|last=Hoholik|first=Suzanne|date=2011-02-14|title=Fewer admissions: Hospital 'observation' status a matter of billing|newspaper=Columbus [Ohio, USA] Dispatch|url=http://www.dispatch.com/live/content/local_news/stories/2011/02/14/hospital-observation-status-a-matter-of-billing.html|access-date=2011-06-03|archive-url=https://archive.is/20130122101749/http://www.dispatch.com/live/content/local_news/stories/2011/02/14/hospital-observation-status-a-matter-of-billing.html|archive-date=2013-01-22|url-status=dead}}</ref>


==Outline==
The primary purpose of the admission note is to provide a detailed record of the patient's condition upon admission, including their [[baseline health]] and initial [[treatment plan]]. Healthcare providers use this document to track the patient's progress and make informed decisions about their care.
An exhaustive admission note might not encompass every component delineated below. Nonetheless, an ideal admission note would encapsulate:
 
Admission notes are often followed by other [[clinical documentation]], such as:
* '''[[Progress notes]]''' ([[SOAP note]]s)
* '''[[Preoperative notes]]''' and '''[[Postoperative notes]]'''
* '''[[Procedure notes]]'''
* '''[[Discharge summaries]]'''
 
== Components of an Admission Note ==
 
An admission note typically consists of several key sections, which may vary depending on the patient's condition and the facility's documentation standards.


=== Header ===
=== Header ===
* Identification attributes of the patient:
* Patient information:
** Name
* Name
** ID number
* ID number
** Chart number
* Chart number
** Room assignment
* Room number
** Date of birth
* Date of birth
** Primary physician
* Gender
** Gender
* Primary physician
** Admission timestamp
* Admission time and date
* Current Date
* Service or department responsible for the patient
* Precise Time
* Applicable Service


=== Chief Complaint (CC) ===
=== Chief Complaint (CC) ===
{{main|Chief complaint}}
{{main|Chief complaint}}
A concise statement usually spanning a sentence that entails:
A brief statement that summarizes the reason for admission. Example:
* Age
* "45-year-old male presenting with acute [[chest pain]] and [[shortness of breath]]."
* Ethnicity
* Gender
* Pertinent complaint
* For instance: "34 yo Caucasian male showcasing right-side weakness accompanied by speech impediments."


=== History of Present Illness (HPI) ===
=== History of Present Illness (HPI) ===
{{main|History of the present illness}}
{{main|History of the present illness}}
* Present health metrics
A detailed account of the patient's symptoms, including:
* Thorough analysis of the chief complaint
* Onset, duration, and progression of symptoms
* Relevant symptoms aligned with the provisional diagnosis formulated by the health care provider.
* Factors that worsen or relieve symptoms
* Emergency measures and resultant patient responses, if pertinent.
* Any prior treatments or emergency interventions
* Associated symptoms relevant to the primary complaint


=== Allergies ===
=== Allergies ===
{{main|Allergy}}
{{main|Allergy}}
* Allergen exposure and ensuing response, sequenced chronologically.
* Documentation of [[drug allergies]], [[food allergies]], and environmental sensitivities.
* Description of reactions to allergens.


=== Past Medical History (PMHx) ===
=== Past Medical History (PMHx) ===
An inventory of the patient's lingering health issues. The chronic ailments should be distinctly labeled as well-managed or otherwise. Relevant timestamps should accompany significant items.
{{main|Medical history}}
A summary of the patient's preexisting conditions, including:
* Chronic diseases such as [[hypertension]], [[diabetes]], or [[heart disease]]
* Previous [[hospitalizations]] and [[significant medical events]]


=== Past Surgical History (PSurgHx, PSxHx) ===
=== Past Surgical History (PSurgHx) ===
A chronological list of past surgical procedures, with dates for notable events.
{{main|Surgical history}}
A chronological list of prior [[surgeries]] and [[procedures]], including:
* Type of surgery
* Date (if known)
* Any complications


=== Family History (FmHx) ===
=== Family History (FmHx) ===
{{Main|Family history (medicine)}}
{{main|Family history (medicine)}}
Health specifics or cause of demise for:
A record of significant medical conditions in close relatives, including:
* Parents
* [[Genetic disorders]]
* Siblings
* [[Cardiovascular disease]]
* Offspring
* [[Cancer]]
* Life partner
* [[Autoimmune diseases]]


=== Social History (SocHx) ===
=== Social History (SocHx) ===
:{{main|Social history (medicine)}}
{{main|Social history (medicine)}}
A segment of the admission note that sheds light on familial, occupational, and recreational facets of the patient's life with potential clinical implications.
Information about lifestyle and environmental factors affecting health:
* [[Occupation]] and [[workplace exposures]]
* [[Tobacco smoking]], [[alcohol consumption]], and [[substance use]]
* [[Living conditions]] and [[social support system]]
* Recent [[travel history]] (relevant in cases of [[infectious disease]])


=== Medications ===
=== Medications ===
{{main|Pharmaceutical drug}}
{{main|Medication}}
Details for each drug include:
A list of all [[pharmaceutical drugs]] the patient is taking, including:
* Generic name
* Generic and brand names
* Dosage  
* Dosage and frequency
* Administration frequency
* Over-the-counter drugs, [[herbal supplements]], and [[homeopathic remedies]]
* Medications on arrival ([[aspirin]], Goody's medicated powder, [[herbal remedies]], [[Prescription drug|prescriptions]], etc.)
* Medications during transfer


=== Review of Systems (ROS) ===
=== Review of Systems (ROS) ===
{{Main|Review of systems}}
{{main|Review of systems}}
A comprehensive review spanning multiple systems:
A structured review of the body's major systems to identify any additional symptoms:
* General health status
* '''General:''' Weight loss, fatigue, fever
* And subsequent organ/system-specific reviews...
* '''Cardiovascular:''' Chest pain, palpitations
* '''Respiratory:''' Cough, wheezing
* '''Gastrointestinal:''' Nausea, vomiting, abdominal pain
* '''Neurological:''' Headaches, weakness, dizziness
* '''Musculoskeletal:''' Joint pain, swelling


=== Physical Examination ===
=== Physical Examination ===
:{{main|Physical examination}}
{{main|Physical examination}}
The '''Physical examination''' or '''clinical examination''' is the tactile assessment where a [[health care provider]] meticulously examines the [[patient]] for any [[sign (medicine)|indicative signs]] of underlying [[disease]].
A head-to-toe assessment that includes:
 
* '''Vital signs:''' [[Blood pressure]], [[heart rate]], [[respiratory rate]], [[temperature]]
=== Labs ===
* '''General appearance:''' Level of distress, [[alertness]]
Examples include tests like [[electrolytes]], [[arterial blood gases]], [[liver function test]]s, and so forth.
* '''Cardiovascular exam:''' [[Heart sounds]], [[murmurs]]
* '''Respiratory exam:''' [[Breath sounds]], [[wheezing]], [[crackles]]
* '''Neurological exam:''' [[Reflexes]], [[cranial nerve]] function
* '''Skin exam:''' [[Rashes]], [[bruising]]


=== Diagnostics ===
=== Laboratory and Diagnostic Tests ===
Examples include [[EKG]], [[Chest radiograph|CXR]], [[X-ray computed tomography|CT]], [[MRI]], among others.
Common tests ordered at admission:
* '''Blood tests:'''
* [[Complete blood count]] (CBC)
* [[Electrolytes]]
* [[Liver function tests]]
* [[Kidney function tests]]
* '''Imaging studies:'''
* [[Chest X-ray]]
* [[CT scan]]
* [[MRI]]
* [[EKG]] (if cardiac issues are suspected)


=== Assessment and Plan ===
=== Assessment and Plan ===
{{main|Assessment and plan}}
{{main|Assessment and plan}}
This section extrapolates on the differential diagnosis with supporting historical data and examination results.
This section includes:
* A summary of the patient's condition and potential [[differential diagnosis]].
* Initial treatment recommendations, such as:
* [[IV fluids]], [[oxygen therapy]], [[antibiotics]]
* [[Surgical consultation]], if needed
* Monitoring and follow-up tests
 
== Importance of the Admission Note ==
An admission note is an essential medical document because it:
* Establishes the baseline [[clinical status]] of the patient.
* Serves as a reference for all healthcare providers involved in the patient's care.
* Ensures continuity of care during the hospital stay.
* Plays a role in [[medical billing]] and [[insurance reimbursement]].
 
== See Also ==
* '''[[Medical documentation]]'''
* '''[[Electronic health record]]'''
* '''[[Hospitalist]]'''
* '''[[SOAP note]]'''
* '''[[Medical chart]]'''


==References==
{{Reflist}}
{{stub}}
{{Medical records}}
{{Medical records}}
{{Telemedicine navbox}}
{{DEFAULTSORT:Admission Note}}
{{DEFAULTSORT:Admission Note}}
[[Category:Medical terminology]]
[[Category:Medical documentation]]
{{No image}}
[[Category:Clinical medicine]]
[[Category:Hospital care]]
[[Category:Medical records]]

Latest revision as of 04:54, 19 March 2025

Admission Note is a crucial component of the medical record that documents a patient's medical history, physical examination findings, and the rationale for their inpatient care admission. This note establishes the foundation for the patient's treatment plan and serves as a reference for healthcare providers throughout the hospital stay.

Purpose[edit]

The primary purpose of the admission note is to provide a detailed record of the patient's condition upon admission, including their baseline health and initial treatment plan. Healthcare providers use this document to track the patient's progress and make informed decisions about their care.

Admission notes are often followed by other clinical documentation, such as:

Components of an Admission Note[edit]

An admission note typically consists of several key sections, which may vary depending on the patient's condition and the facility's documentation standards.

Header[edit]

  • Patient information:
  • Name
  • ID number
  • Chart number
  • Room number
  • Date of birth
  • Gender
  • Primary physician
  • Admission time and date
  • Service or department responsible for the patient

Chief Complaint (CC)[edit]

Main article: Chief complaint

A brief statement that summarizes the reason for admission. Example:

History of Present Illness (HPI)[edit]

Main article: History of the present illness

A detailed account of the patient's symptoms, including:

  • Onset, duration, and progression of symptoms
  • Factors that worsen or relieve symptoms
  • Any prior treatments or emergency interventions
  • Associated symptoms relevant to the primary complaint

Allergies[edit]

Main article: Allergy

Past Medical History (PMHx)[edit]

Main article: Medical history

A summary of the patient's preexisting conditions, including:

Past Surgical History (PSurgHx)[edit]

Main article: Surgical history

A chronological list of prior surgeries and procedures, including:

  • Type of surgery
  • Date (if known)
  • Any complications

Family History (FmHx)[edit]

Main article: Family history (medicine)

A record of significant medical conditions in close relatives, including:

Social History (SocHx)[edit]

Main article: Social history (medicine)

Information about lifestyle and environmental factors affecting health:

Medications[edit]

Main article: Medication

A list of all pharmaceutical drugs the patient is taking, including:

Review of Systems (ROS)[edit]

Main article: Review of systems

A structured review of the body's major systems to identify any additional symptoms:

  • General: Weight loss, fatigue, fever
  • Cardiovascular: Chest pain, palpitations
  • Respiratory: Cough, wheezing
  • Gastrointestinal: Nausea, vomiting, abdominal pain
  • Neurological: Headaches, weakness, dizziness
  • Musculoskeletal: Joint pain, swelling

Physical Examination[edit]

Main article: Physical examination

A head-to-toe assessment that includes:

Laboratory and Diagnostic Tests[edit]

Common tests ordered at admission:

Assessment and Plan[edit]

Main article: Assessment and plan

This section includes:

Importance of the Admission Note[edit]

An admission note is an essential medical document because it:

See Also[edit]


Medical examination and history taking
Medical history
Physical examination
Assessment and plan
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