Admission note

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

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:

• Progress notes (SOAP notes)
• 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

• 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)

Main article: Chief complaint

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

• "45-year-old male presenting with acute chest pain and shortness of breath."

History of Present Illness (HPI)

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

Main article: Allergy

• Documentation of drug allergies, food allergies, and environmental sensitivities.
• Description of reactions to allergens.

Past Medical History (PMHx)

Main article: 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)

Main article: Surgical history

A chronological list of prior surgeries and procedures, including:

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

Family History (FmHx)

Main article: Family history (medicine)

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

• Genetic disorders
• Cardiovascular disease
• Cancer
• Autoimmune diseases

Social History (SocHx)

Main article: Social history (medicine)

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

Main article: Medication

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

• Generic and brand names
• Dosage and frequency
• Over-the-counter drugs, herbal supplements, and homeopathic remedies

Review of Systems (ROS)

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

Main article: Physical examination

A head-to-toe assessment that includes:

• Vital signs: Blood pressure, heart rate, respiratory rate, temperature
• General appearance: Level of distress, alertness
• Cardiovascular exam: Heart sounds, murmurs
• Respiratory exam: Breath sounds, wheezing, crackles
• Neurological exam: Reflexes, cranial nerve function
• Skin exam: Rashes, bruising

Laboratory and Diagnostic Tests

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

Main article: Assessment and plan

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