Admission History & Physical (Neurosurgery)

Date/Time: [Date and time of note entry]

Patient: [Patient name / MRN / DOB]

Location: [Unit/Bed or ED/Observation/ICU]

Service: Neurosurgery H&P

Attending: [Attending physician]

Author: [Author name and role]

Chief Complaint

[Chief complaint] (Use patient's own words in quotes when available. If patient cannot provide, state the source and reason.)

History of Present Illness

[Narrative HPI with explicit timeline] (Open with age, major comorbidities affecting neurosurgical decision-making, and presenting problem. Include onset and last-known-well time, symptom progression, mechanism if traumatic, key neurologic symptoms, and pre-morbid neurologic and functional baseline.)

Prior acute interventions: [Interventions with timing] (Mannitol/hypertonic saline, antiepileptics, anticoagulant reversal, steroids, intubation.)

Antithrombotics: [Agent(s), indication, last dose date/time] (State "Unknown - verification pending" if not confirmed.)

Outside records reviewed: [Sources reviewed and gaps]

History source and limitations: [Source(s) and limitations]

Past Medical History

• [Medical conditions] (Emphasize conditions relevant to neurosurgical care and perioperative risk: anticoagulation indications, bleeding/clotting disorders, cardiac disease, pulmonary disease including OSA, CKD, diabetes, liver disease, prior stroke or ICH, malignancy, immunosuppression.)

Past Surgical History

• [Prior neurosurgical procedures with dates] (Cranial/spine operations, shunts, neurostimulators, CNS radiation.)
• [Other major surgeries with dates]

Medications

Medication reconciliation status: [complete / pending]

• [Home medications with dose, route, frequency] (Explicitly state "unknown" for unverified elements rather than omitting.)

High-impact medications:

• Antiplatelets/Anticoagulants: [Agent(s), indication, last dose date/time, reversal if given]
• Antiepileptics: [Agent(s) and regimen]
• Steroids: [Agent(s) and regimen]
• Opioids: [Agent(s) and regimen]
• Antihypertensives: [Agent(s) and regimen]

Allergies

[Allergies with reaction type and severity] (State "NKDA" if none, or "Unknown - verification pending" if unverified.)

Family History

[Relevant family history] (Include aneurysm/SAH, early stroke, bleeding disorders, malignant hyperthermia if surgery likely. State "Noncontributory" or "Unable to obtain" as appropriate.)

Social History

• Tobacco: [Use status]
• Alcohol: [Use status and withdrawal risk]
• Substances: [Use status]
• Baseline function: [Living situation, mobility, assistive devices]
• Occupation: [Occupation if relevant]

Review of Systems

(Targeted ROS only. Do not auto-populate systems not obtained. State if limited and why.)

• Neurologic: [Focal deficits, headache, seizures, LOC/AMS, gait changes]
• Constitutional: [Fever/chills, weight changes, fatigue]
• Cardiopulmonary: [Chest pain, dyspnea, palpitations]
• GI: [Nausea/vomiting]
• GU: [Retention/incontinence]

Physical Examination

Vitals: [Most recent vitals with clinically relevant trends]

General: [Appearance, airway/respiratory support, hemodynamic stability]

HEENT: [Trauma signs, meningismus]

Cardiovascular: [Heart sounds, perfusion]

Pulmonary: [Breath sounds, work of breathing]

Extremities: [Edema, DVT signs]

Skin/Wounds: [Surgical sites, lacerations, pressure injury risk]

Neurologic Examination

Mental Status: [Alertness, orientation, attention, command-following; GCS (E/V/M) if applicable]

Speech/Language: [Fluency, naming, comprehension, dysarthria]

Cranial Nerves: [Pupils (size/reactivity/symmetry), EOMs, facial symmetry, other CNs as relevant]

Motor: [Strength by muscle groups with laterality and 0-5 scale; bulk, tone, pronator drift]

Sensory: [Light touch at minimum; pinprick/temperature/vibration/proprioception as indicated]

Reflexes: [DTRs; Babinski/Hoffman if indicated]

Coordination: [Finger-nose, heel-shin, rapid alternating movements]

Gait: [Observed findings / Deferred for safety]

Exam Limitations: [What could not be tested and why] (Always document limitations explicitly.)

Spine-Focused Neurologic Examination (Include only if spine, spinal cord, or cauda equina pathology suspected or confirmed.)

• Motor by myotomes: [Strength by key myotomes with laterality]
• Sensory by dermatomes: [Light touch/pinprick by key dermatomes with laterality]
• Upper motor neuron signs: [Clonus, Babinski, Hoffman]
• Bowel/Bladder/Saddle sensation: [Findings or "Deferred" with reason]
• Spinal precautions: [in place / not required / pending evaluation]
• (For confirmed or suspected spinal cord injury, note plan for ASIA/ISNCSCI examination.)

Diagnostics

Laboratory Results

[Key abnormal values with context] (CBC, BMP, coagulation studies, type and screen. Note critical values and actions taken.)

Imaging Summary

(List newest to oldest. For each: modality, anatomic region, date/time, source, and whether personally reviewed.)

• [Study 1: Modality, region, date/time, source, personally reviewed: yes/no]
  [Neurosurgery-focused impression in 1-3 sentences] (Include key measurements, mass effect, and surgical anatomy as applicable.)
• [Study 2: Modality, region, date/time, source, personally reviewed: yes/no]
  [Neurosurgery-focused impression]

Other Studies

[EKG, EEG, ICP monitoring/EVD data, angiography, other pertinent diagnostics] (Include only if relevant.)

Assessment and Plan

[Summary paragraph] (Synthesize condition, acuity, key imaging findings, and current neurologic status.)

1. [Problem 1 - primary neurosurgical diagnosis]: [Working diagnosis with severity; differential if uncertain]

   • Level of care: [ICU/stepdown/floor; neuro check frequency; ICP targets if applicable]
   • Physiologic targets: [BP/MAP/CPP goals; oxygenation; temperature; glucose]
   • Medications: [Analgesia/sedation; antiepileptics; steroids; antibiotics]
   • DVT prophylaxis: [Mechanical/pharmacologic; rationale if held]
   • Antithrombotic management: [Hold/reverse/bridge plan]
   • Imaging follow-up: [Modality, timing, triggers for urgent imaging]
   • Consults: [Service and clinical question]
   • Lines/Drains/Devices: [EVD/drain management; Foley necessity; shunt settings]
   • Diet/Activity/Rehab: [NPO status; spine precautions; PT/OT/SLP]
   • Goals of care: [Code status; surrogate; family communication plan]

2. [Problem 2]: [Assessment and plan] (Include relevant domains from above.)

3. [Additional problems as applicable]

Perioperative Assessment

(Include only if surgery or procedure is planned or likely. Otherwise omit this section.)

• Planned Procedure: [Name, indication, urgency: emergent/urgent/elective]
• Consent Status: [obtained / pending / unable to obtain with pathway noted]
• NPO Status: [Last oral intake time]
• Anesthesia Considerations: [OSA, aspiration risk, C-spine precautions, anticoagulation status]
• Cardiovascular Risk: [Functional capacity; need for additional testing]
• Perioperative Medication Plan: [Medications to hold or continue]
• Blood Products: [Type and screen/crossmatch status; anticipated blood loss]

Admission Orders Summary

• Admit to: [Service, attending, level of care]
• Admitting Diagnosis: [Diagnosis]
• Monitoring: [Neuro check and vitals frequency; telemetry]
• Diet: [NPO / regular / tube feeds; aspiration precautions]
• Activity: [Bedrest / ambulate with assist / spine precautions]
• DVT Prophylaxis: [Mechanical/pharmacologic and timing]
• Labs: [Scheduled labs and timing]
• Imaging: [Planned imaging and timing]
• Consults: [Consults placed]