Admission note

Admission Note is a pivotal part of the medical record that chronicles the patient's status encompassing history and 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">

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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 professionals utilize these notes to document a patient's foundational health state. Subsequent notes, such as on-service notes, progress notes (SOAP notes), preoperative notes, operative notes, postoperative notes, procedure notes, delivery notes, postpartum notes, and discharge notes, 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 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"> </ref>

Outline

An exhaustive admission note might not encompass every component delineated below. Nonetheless, an ideal admission note would encapsulate:

Header

• Identification attributes of the patient:
  • Name
  • ID number
  • Chart number
  • Room assignment
  • Date of birth
  • Primary physician
  • Gender
  • Admission timestamp
• Current Date
• Precise Time
• Applicable Service

Chief Complaint (CC)

Main article: Chief complaint

A concise statement usually spanning a sentence that entails:

• Age
• Ethnicity
• Gender
• Pertinent complaint
• For instance: "34 yo Caucasian male showcasing right-side weakness accompanied by speech impediments."

History of Present Illness (HPI)

Main article: History of the present illness

• Present health metrics
• Thorough analysis of the chief complaint
• Relevant symptoms aligned with the provisional diagnosis formulated by the health care provider.
• Emergency measures and resultant patient responses, if pertinent.

Allergies

Main article: Allergy

• Allergen exposure and ensuing response, sequenced chronologically.

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.

Past Surgical History (PSurgHx, PSxHx)

A chronological list of past surgical procedures, with dates for notable events.

Family History (FmHx)

Main article: Family history (medicine)

Health specifics or cause of demise for:

• Parents
• Siblings
• Offspring
• Life partner

Social History (SocHx)

Main article: 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.

Medications

Main article: Pharmaceutical drug

Details for each drug include:

• Generic name
• Dosage
• Administration frequency
• Medications on arrival (aspirin, Goody's medicated powder, herbal remedies, prescriptions, etc.)
• Medications during transfer

Review of Systems (ROS)

Main article: Review of systems

A comprehensive review spanning multiple systems:

• General health status
• And subsequent organ/system-specific reviews...

Physical Examination

Main article: Physical examination

The Physical examination or clinical examination is the tactile assessment where a health care provider meticulously examines the patient for any indicative signs of underlying disease.

Labs

Examples include tests like electrolytes, arterial blood gases, liver function tests, and so forth.

Diagnostics

Examples include EKG, CXR, CT, MRI, among others.

Assessment and Plan

Main article: Assessment and plan

This section extrapolates on the differential diagnosis with supporting historical data and examination results.

References

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