Adult Acute-Care Hospital Admission History & Physical (Inpatient/Observation)

Date/Time of Service: [Date and time of encounter]

Author/Service: [Author role and service name]

Location: [ED / ward / ICU]

Admission Status: [inpatient / observation]

Source of History: [Sources of information and reliability/limitations] (List sources used such as patient, family, EMS, outside records, pharmacy; document limitations on reliability such as delirium, intubation, language barrier, hearing/vision impairment.)

Admitting Diagnosis: [Working admitting diagnosis or syndrome]

Chief Complaint

[One-line statement of the primary concern] (Use the patient's own words when feasible; include direct quotes when they clarify priorities or ambiguity.)

History of Present Illness

[Narrative account of current illness] (Begin with context of the chief complaint, then provide a chronological description including onset, duration, characteristics, severity and trajectory, aggravating/alleviating factors, associated symptoms, and pertinent negatives tied to the differential. Include prior episodes, pre-hospital/ED treatments and response, and relevant comorbidities that affect the presentation. Add baseline function, recent procedures/travel/exposures, and device history if pertinent. Briefly note red-flag diagnoses considered when applicable. Synthesize information from ED and outside notes—do not copy verbatim; include updates since ED evaluation. If information is missing, explicitly state what is unknown and why.)

Prior Course

[Key events impacting current admission] (Include this section only when prior care materially affects current decisions. For ED admits: summarize key vitals/events, major interventions, response, and rationale for admission. For transfers: list key diagnoses, treatments such as antibiotics/pressors/anticoagulation, major imaging/labs, procedures, and pending results from the outside facility. For direct admits: connect outpatient deterioration to inpatient goals. Omit this section entirely if not applicable.)

Past Medical History

• [Active medical problems with brief qualifiers] (Include severity/control and relevance to current care.)
• [Key disease-specific details] (Include data such as last A1c for diabetes, EF for heart failure, baseline creatinine for CKD, home oxygen for COPD, immunosuppressants, transplant history, cancer treatment status—only if known and relevant.)
• [Relevant surgical/procedural history] (Include implanted devices, prior vascular access, bariatric surgery, and relevant resections.)
• [OB/GYN history] (Include only when clinically relevant.)

(If history is unobtainable, document the limitation and source of available information.)

Medications

Home Medications: [Structured list: name, dose, route, frequency; last taken when relevant] (Explicitly include OTCs, supplements, herbals, eye drops, inhalers, topicals, injections.)

Reconciliation Status: [Sources used and reconciliation status] (Document sources such as patient/family report, pharmacy fill history, facility MAR, prior discharge list. Note discrepancies identified and how resolved or plan to resolve; list intentional holds/changes with rationale. If incomplete, state: "Medication history incomplete—[plan to obtain]; will update within 24 hours.")

High-Risk Medications: [Anticoagulants, insulin, opioids/benzodiazepines, immunosuppressants] (For each present, document indication, last dose/time, and relevant safety considerations. Omit if none present.)

Allergies

[Allergen with reaction type and severity] (Distinguish true allergy from intolerance. If none, document explicitly: NKDA.)

Social History & Baseline Function

• Living Situation: [Residence, caregivers, home supports]
• Baseline Function: [Mobility, ADLs, assistive devices, falls history]
• Substance Use: [Tobacco, alcohol, recreational drugs] (Quantify; include last use if relevant.)
• Occupation/Exposures: [Relevant occupational or environmental exposures] (Include only when relevant.)
• Facility Residents: [Facility name, baseline cognition/behavior] (For SNF/ALF patients only.)

Review of Systems

[Focused ROS] (Include only findings that add diagnostic clarity beyond the HPI. Omit or abbreviate if already captured in HPI without additional value. If unable to obtain due to intubation, encephalopathy, or language barrier, document why and what source was used instead.)

Physical Examination

Vitals: [BP, HR, RR, Temp, SpO₂, weight] (Include oxygen device and settings when applicable.)

General: [Appearance, mental status, distress/toxicity, hydration, work of breathing]

• HEENT: [Pertinent findings]
• Neck: [Pertinent findings]
• Cardiovascular: [Heart sounds, rhythm, perfusion, edema]
• Respiratory: [Breath sounds, effort, accessory muscle use]
• Abdomen: [Tenderness, distension, bowel sounds]
• Extremities/MSK: [Strength, tenderness, deformity, edema]
• Skin: [Rashes, wounds, pressure injury risk/findings]
• Neuro: [Orientation, focal deficits, gait if assessed]
• GU: [Pertinent findings] (Include only if clinically relevant.)
• Psych: [Affect, thought process] (Include only if clinically relevant.)

Lines/Devices/Wounds: [Oxygen device/settings, IV access, Foley, drains, central lines, trach/PEG, ostomies, wounds/pressure injuries] (Include date/time placed when known.)

(If exam is limited, document why and what was performed.)

Data Review

• Labs: [Abnormal and decision-driving values with date/time] (Highlight clinically significant results; do not list every normal.)
• Imaging: [Modality, date/time, key findings] (Summarize; do not copy full report.)
• ECG/Telemetry: [Your interpretation: rate, rhythm, intervals, ischemic changes, date/time] (Include only if performed.)
• Microbiology: [Source, collection time, preliminary vs final results, susceptibilities] (Include only if obtained.)
• Outside Records: [External sources reviewed and key takeaways] (Include prior echo, cath reports, discharge summaries as relevant.)

Assessment

Clinical Summary: [One-sentence synopsis: age/sex, key comorbidities, working diagnosis/syndrome, severity, and why hospitalization is required]

Problem List

[Problem 1]: [Working diagnosis or syndrome] — [improving / stable / worsening]. [Key supporting data, differential diagnosis when uncertainty exists, reasoning for favored diagnosis and what is being ruled out, relevant risk factors such as hemodynamics, comorbidities, need for IV therapy/monitoring.]

[Problem 2]: [Working diagnosis or syndrome] — [improving / stable / worsening]. [As above.]

(Continue for additional problems in order of acuity; include chronic problems that affect management.)

Independent Review/Discussions: [Data reviewed independently with your interpretation; discussions with consultants/ED/OSH clinicians; external records reviewed]

Status Determination

Admission Status: [inpatient / observation]

[Status rationale] (For observation: document why observation is appropriate and explicit discharge/readiness criteria such as pain controlled on PO meds, serial biomarkers negative, ambulatory oxygen acceptable, tolerating PO with safe discharge plan. For inpatient: document what requires inpatient-level intensity such as IV therapies, frequent reassessment, high risk of deterioration, or complex comorbidity management, and the expectation of care spanning two midnights.)

Plan

[Problem 1]: [Diagnosis or syndrome]

• Diagnostics: [Planned labs, imaging, cultures, monitoring parameters]
• Therapeutics: [Medications with dose/route/frequency; fluids; oxygen/ventilation; procedures]
• Monitoring: [Vitals frequency, telemetry, neuro checks, intake/output, daily weights]
• Consults: [Service and rationale] (If applicable.)
• Contingencies: [Explicit actions if deterioration or thresholds crossed]

[Problem 2]: [Diagnosis or syndrome]

• Diagnostics: [As above]
• Therapeutics: [As above]
• Monitoring: [As above]
• Consults: [As above]
• Contingencies: [As above]

(Repeat for additional problems as needed.)

Hospital Care Bundle

• Level of Care: [ICU / stepdown / telemetry / med-surg] — [brief rationale]
• Code Status: [Full code / DNR / DNI / DNR-DNI / comfort care] — [discussion summary, surrogate decision-maker, advance directives if known]
• VTE Prophylaxis: [pharmacologic / mechanical / contraindicated] — [agent or rationale]
• Diet: [Diet order]
• Activity: [Activity level, fall precautions]
• Glycemic Management: [Plan, targets, insulin strategy] (Include if diabetic or on steroids.)
• Lines/Tubes: [Device, indication, removal plan] (For Foley, central lines, drains.)
• Isolation: [Precaution type and indication] (If applicable.)
• Therapies: [PT / OT / SLP evaluations] (Order when disposition or function is impacted.)

Disposition & Anticipated Course

Expected Trajectory: [Anticipated improvement over 24–72 hours; key uncertainties]

Disposition Plan: [home / home with services / SNF / rehab / other] — [Barriers: oxygen needs, mobility, dialysis, placement, IV antibiotics, pending workup]

Communication

• Patient/Family: [Updates provided, shared decision-making summary, high-risk choices discussed]
• PCP/Specialists: [Notification status] (If relevant.)
• Consults Requested: [Service and purpose]
• Interpreter: [Language and modality] (If used.)

(Safety-critical information such as medications, allergies, and code status should never be omitted; if unknown, include a placeholder with plan to obtain promptly. For non-critical missing information, omit or note "not obtained" with rationale when clinically important. Clinical inference belongs in the Assessment and should be labeled as such; do not infer factual history elements. Omit sections that do not apply.)