An admission note is part of a medical record that documents the patient's status, reasons why the patient

Patient

A patient is any recipient of healthcare services. The patient is most often ill or injured and in need of treatment by a physician, advanced practice registered nurse, veterinarian, or other health care provider....

 is being admitted for inpatient care

Inpatient care

Inpatient care is the care of patients whose condition requires admission to a hospital. Progress in modern medicine and the advent of comprehensive out-patient clinics ensure that patients are only admitted to a hospital when they are extremely ill or are have severe physical...

 to a hospital or other facility, and the initial instructions for that patient's care.

Purpose

Admission notes document the reasons why a patient

Patient

A patient is any recipient of healthcare services. The patient is most often ill or injured and in need of treatment by a physician, advanced practice registered nurse, veterinarian, or other health care provider....

 is being admitted for inpatient care

Inpatient care

Inpatient care is the care of patients whose condition requires admission to a hospital. Progress in modern medicine and the advent of comprehensive out-patient clinics ensure that patients are only admitted to a hospital when they are extremely ill or are have severe physical...

 to a hospital or other facility, the patient's baseline status, and the initial instructions for that patient's care. Health care professionals use them to record a patient's baseline status and may write additional on-service notes, progress note

Progress note

Progress Notes are the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. Reassessment data may be recorded in the Progress Notes, Master...

s (SOAP note

SOAP note

The SOAP note is a method of documentation employed by health care providers to write out notes in a patient's chart, along with other common formats, such as the admission note...

s), preoperative notes, operative notes, postoperative notes, procedure notes, delivery notes, postpartum notes, and discharge notes. These notes constitute a large part of the medical record

Medical record

The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction....

. Medical students often develop their clinical reasoning skills by writing admission notes. The traditional, rational definition of being admitted usually involves spending an overnight in the hospital. This definition is sometimes stretched in the U.S. medical billing industry

Medical billing (United States)

Medical billing & coding is the process of submitting and following up on claims to insurance companies in order to receive payment for services rendered by a healthcare provider. The same process is used for most insurance companies, whether they are private companies or government-owned...

, where hospital corporations sometimes blur the definition of "admission" versus "observation" because of reimbursement rules that pay less for the care if an "admission" was involved. An article in the Columbus [Ohio, USA] Dispatch newspaper gives an example.used by healthcare payors to determine billing;

Components

An admission note may sometimes be incorrectly referred to as an HPI (history of present illness) or H and P (history and physical), which include only portions of an admission note.

An admission note can include the following sections:

Section	Example	Comments
chief complaint Chief complaint The Chief Complaint formally known as CC in the medical field, or termed Presenting Complaint in the UK, is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for a medicalencounter...  (CC)	"abdominal pain"	Can also include a more detailed line, such as "30 yo F c/o abdominal pain", though this can be redundant to the HPI. Some notes include a "reason for consultation", which is similar but may address a physical finding from a physician as opposed to a symptom Symptom A symptom is a departure from normal function or feeling which is noticed by a patient, indicating the presence of disease or abnormality...  from a patient.
history of present illness (HPI)	"Pt is a 30 yo female (with a PMH of x and y) presenting with a 3 hour history of abdominal pain Abdominal pain Abdominal pain can be one of the symptoms associated with transient disorders or serious disease. Making a definitive diagnosis of the cause of abdominal pain can be difficult, because many diseases can result in this symptom. Abdominal pain is a common problem... ..."	Including a separate paragraph summarizing related history. May follow OPQRST Opqrst "PQRST" is sometimes used instead.The term "OPQRST-AAA" adds "aggravating/alleviating factors", "associated symptoms", and "attributions/adaptations".-Meaning:The parts of the mnemonic are:...  or similar format. Components from review of systems may be moved here if they are seen as relevant to the chief complaint. May exclude first line if this information is included in CC section.
review of systems Review of systems A review of systems is a technique used by health-care providers for eliciting a history from a patient. It is often structured as a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient...  (ROS)	"negative except as above"	Brief or handwritten ROS sections are often very brief, while template-driven ROS sections from electronic medical records often explicitly enumerate each system reviewed.
allergies	"NKDA"	including drug allergies (including antigens and responses). "NKA" = "no known allergies". "NKDA" = "no known drug allergies". Some sources include both acronyms, which reduces ambiguity between drug allergies and other allergies (such as food allergies or allergies to pets)
medications	"none"	Includes both prescription and over-the-counter medications. May also include herbal medications or nutritional supplements. May include data on dosage and compliance.
past medical history Past medical history In a medical encounter, a past medical history , is the total sum of a patient's health status prior to the presenting problem.-Questions to include:...  (PMH)	"none"	Although remote childhood PMH is sometimes omitted, this information can sometimes be useful (for example, childhood asthma Asthma Asthma is the common chronic inflammatory disease of the airways characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm. Symptoms include wheezing, coughing, chest tightness, and shortness of breath...  can be associated with adult atopic disorders.)
past surgical history (PSH)	"none"	Admissions to a hospital not associated with a surgery are also sometimes included here, though admissions associated with childbirth Childbirth Childbirth is the culmination of a human pregnancy or gestation period with the birth of one or more newborn infants from a woman's uterus...  are often described in a distinct section. For example, a "OB/GYN" section may be included, including language such as "G3P2 Gravida/para/abortus Gravida/para/abortus , or sometimes just gravida/para , is a shorthand notation for a woman's obstetric history.* Gravida indicates the number of times the mother has been pregnant, regardless of whether these pregnancies were carried to term. A current pregnancy, if any, is included in this... , menarche Menarche Menarche is the first menstrual cycle, or first menstrual bleeding, in female human beings. From both social and medical perspectives it is often considered the central event of female puberty, as it signals the possibility of fertility....  at age 14, LMP Gestational age Gestational age relates to the age of an embryo or fetus . There is some ambiguity in how it is defined:*In embryology, gestational age is the time elapsed since conception. This interval is also termed fertilisation age....  2 weeks ago, regular".
family history Family history Family history is the systematic narrative and research of past events relating to a specific family, or specific families.- Introduction :...  (FH)	"noncontributory"	Including health of siblings, parents, spouse, and children, living and dead. Age of diagnosis may also be included (for example, in conditions such as colon cancer). A phrase such as "no family h/o of heart or lung problems" may be used to specifically indicate that questions about a system were asked.
social history Social history (medicine) In medicine, a social history is a portion of the Admission note addressing familial, occupational, and recreational aspects of the patient's personal life that have the potential to be clinically significant.-Components:...  (SH)	"Denies x3"	Can be very detailed. Usually includes information about tobacco Tobacco Tobacco is an agricultural product processed from the leaves of plants in the genus Nicotiana. It can be consumed, used as a pesticide and, in the form of nicotine tartrate, used in some medicines...  use, alcohol Alcohol In chemistry, an alcohol is an organic compound in which the hydroxy functional group is bound to a carbon atom. In particular, this carbon center should be saturated, having single bonds to three other atoms.... , and illegal or recreational drugs DRUGS Destroy Rebuild Until God Shows are an American post-hardcore band formed in 2010. They released their debut self-titled album on February 22, 2011.- Formation :... . Each of these may include quantities or frequencies, and responses to CAGE CAGE questionnaire The CAGE questionnaire, the name of which is an acronym of its four questions, is a widely used method of screening for alcoholism.The CAGE questionnaire, among other methods, has been extensively validated for use in identifying alcoholism...  questions may be reported. May also include information about travel Travel Travel is the movement of people or objects between relatively distant geographical locations. 'Travel' can also include relatively short stays between successive movements.-Etymology:...  and occupation Occupation Occupation may refer to:*Job , a regular activity performed for payment, that occupies one's time**Employment, a person under service of another by hire**Career, a course through life**Profession, a vocation founded upon specialized training... . May also include sexual history, though this may be split off in a separate section.
physical exam	see Physical examination#Example	see Physical examination#Example
labs Labs Labs, labs, or LABS may carry the following meanings:* a type of dog known as the Labrador retriever* labs, a function that calculates the absolute value of a long integer in the C programming language* a spoken form or short form of laboratory...  and diagnostics studies	"none"	May cover studies performed at an outside hospital, during prior admissions, or in the ER before the current admission.
assessment and plan Assessment and plan The assessment and plan is a component of an admission note.* Assessment includes a discussion of the differential diagnosis and supporting history and exam findings.* The plan is typically broken out by problem or system...  (A&P)	"Pt is a 30 yo female..."	Assessment and plan are very closely related, and are often reported in a single section. May be begun with a paragraph that is similar to the first line of the HPI, but with a greater emphasis on clinical reasoning. A list of problems may be organized by priority or by organ system, with specific actions associated with each item on the problem list. Additional sections for "fluids, electrolytes, and nutrition" and "disposition" may be added near the end.

Outline

Not every admission note explicitly discusses every item listed below, however, the ideal admission note would include:

Header

• Patient identifying information (maybe located separately)
  • name
  • ID number
  • chart number
  • room number
  • date of birth
  • attending physician
  • sex
  • admission date
• Date
• Time
• Service

Chief complaint (CC)

Typically one sentence including

• age
• race
• sex
• presenting complaint
• example: "34 yo white male with right-sided weakness and slurred speech."

History of present illness (HPI)

• statement of health status
• detailed description of chief complaint
• positive and negative symptoms related to the chief complaint based on the differential diagnosis the health care provider has developed.
• emergency actions taken and patient responses if relevant

Past Medical History (PMHx)

List of the patient's on-going medical problems. Chronic problems should be addressed as to whether or not they are well controlled or uncontrolled. Include dates of pertinent items.

Past Surgical History (PSurgHx, PSxHx)

List of surgeries in the past with dates of pertinent items.

Family history (FmHx)

Health or cause of death for:

• Parents
• Siblings
• Children
• Spouse

Social History (SocHx)

In medicine, a social history is a portion of the admission note addressing familial, occupational, and recreational aspects of the patient's personal life that have the potential to be clinically significant.

Medications

• for each: generic name - amount - rate
• medications on arrival (aspirin
  Aspirin
  Aspirin , also known as acetylsalicylic acid , is a salicylate drug, often used as an analgesic to relieve minor aches and pains, as an antipyretic to reduce fever, and as an anti-inflammatory medication. It was discovered by Arthur Eichengrun, a chemist with the German company Bayer...
  
  , Goody's medicated powder, herbal remedies, prescriptions
  Prescription drug
  A prescription medication is a licensed medicine that is regulated by legislation to require a medical prescription before it can be obtained. The term is used to distinguish it from over-the-counter drugs which can be obtained without a prescription...
  
  , etc)
• medications on transfer

Physical exam

Physical examination or clinical examination is the process by which a health care provider

Health care provider

A health care provider is an individual or an institution that provides preventive, curative, promotional or rehabilitative health care services in a systematic way to individuals, families or communities....

 investigates the body of a patient

Patient

A patient is any recipient of healthcare services. The patient is most often ill or injured and in need of treatment by a physician, advanced practice registered nurse, veterinarian, or other health care provider....

 for signs of disease

Disease

A disease is an abnormal condition affecting the body of an organism. It is often construed to be a medical condition associated with specific symptoms and signs. It may be caused by external factors, such as infectious disease, or it may be caused by internal dysfunctions, such as autoimmune...

.

Review of systems (ROS)

• General
• Head
• Eyes
• Ears
• Nose and sinuses
• Throat, mouth, and neck
• Breasts
• Cardiovascular system
• Respiratory system
  Respiratory system
  The respiratory system is the anatomical system of an organism that introduces respiratory gases to the interior and performs gas exchange. In humans and other mammals, the anatomical features of the respiratory system include airways, lungs, and the respiratory muscles...
  
  
• Gastrointestinal system
• Urinary system
  Urinary system
  The urinary system is the organ system that produces, stores, and eliminates urine. In humans it includes two kidneys, two ureters, the bladder and the urethra.-Kidney:...
  
  
• Genital system
• Vascular system
• Musculoskeletal system
  Musculoskeletal system
  A musculoskeletal system is an organ system that gives animals the ability to move using the muscular and skeletal systems...
  
  
• Nervous system
  Nervous system
  The nervous system is an organ system containing a network of specialized cells called neurons that coordinate the actions of an animal and transmit signals between different parts of its body. In most animals the nervous system consists of two parts, central and peripheral. The central nervous...
  
  
• Psychiatric
• Hematologic system
• Endocrine system
  Endocrine system
  In physiology, the endocrine system is a system of glands, each of which secretes a type of hormone directly into the bloodstream to regulate the body. The endocrine system is in contrast to the exocrine system, which secretes its chemicals using ducts. It derives from the Greek words "endo"...
  
  

Assessment and Plan

Assessment includes a discussion of the differential diagnosis and supporting history and exam findings.