Ayurveda Inpatient Admission Note (H&P)

Date/Time of Admission: [Date and time of admission]

Date/Time of Note: [Date and time of documentation]

Author: [Author name and credentials]

Patient Name: [Full name]

MRN: [Medical record number]

DOB/Age: [Date of birth / Age]

Sex: [Sex]

Location (Ward/Bed): [Ward/Unit and Bed]

Admission Type: [elective / urgent / emergent]

Source of History: [patient / caregiver / medical records / other] (Note interpreter use if applicable; indicate history reliability: reliable, limited, or unknown)

Allergies: [Allergen(s), reaction type, severity, and recency; include reactions to oils, latex, adhesives, and procedure materials if relevant] (If none, state "No known allergies"; if incomplete, state "Allergy history incomplete—pending verification")

Chief Complaint

[Primary reason for admission in one to two sentences using patient wording when helpful] (For planned Panchakarma, document as procedure-driven, e.g., "Admission for supervised Virechana"; if multiple problems, list the dominant inpatient driver first)

History of Present Illness

[Chronological narrative of the presenting illness beginning with the chief complaint: onset, duration, frequency, severity, location, quality, progression, aggravating/relieving factors, associated symptoms, impact on sleep/appetite/mobility, prior evaluations and treatments (Ayurvedic and conventional), response to therapy, and relevant red flags] (Explicitly state why inpatient care is required rather than outpatient management; if history cannot be obtained, document why and what alternate sources were used)

Ayurveda-Relevant History: [Key nidāna/hetu; doṣa-aggravating features; prior Panchakarma history and tolerance; baseline bowel habit and koṣṭha tendency] (Include only if assessed and relevant to the admission plan)

Past History

• Past Medical History: [Chronic conditions with dates; include both biomedical and Ayurvedic diagnoses] (Use "Unknown" if unavailable)
• Past Surgical/Procedural History: [Surgeries and procedures with dates; include prior Panchakarma and any complications] (Use "Unknown" if unavailable)
• Obstetric/Gynecologic History: [Pregnancy status, LMP, lactation] (Include when applicable; use "Unknown" if unavailable)
• Psychiatric History: [Diagnoses, treatments, hospitalizations] (Include when relevant to safety or adherence; use "Unknown" if unavailable)
• Prior Hospitalizations and Notable Complications: [Dates, indications, adverse drug reactions] (Use "Unknown" if unavailable)

Medications, Herbals, and Allergies

(For each medication or herbal, include name, dose, route, frequency, timing relative to meals, duration, and anupāna/vehicle when clinically important; note adherence status and last dose time for key medications; flag recent steroids, NSAIDs, or anticoagulants; if list is incomplete, document "Medication list incomplete—pending verification")

• Ayurvedic Formulations: [Name (classical/brand), dose, route, frequency, timing, duration, anupāna, indication, last dose time]
• Conventional Medications: [Name, dose, route, frequency, timing, duration, indication, last dose time]
• OTC/Supplements: [Name, dose, frequency, duration]
• Adherence: [adherent / partially adherent / nonadherent / unknown] (Include barriers if stated)
• Allergies: [Substance, reaction type, severity, recency] (Include oils, latex, adhesives, procedure materials if relevant to planned therapies)

Family and Social History

• Family History: [Hereditary conditions relevant to presentation; relationship and age of onset when known] (Use "Unknown" if unavailable)
• Living Situation/Caregiver Support: [Residence type, household members, caregiver availability]
• Occupation: [Role, exposures, shift work, stressors]
• Tobacco/Alcohol/Substance Use: [Type, quantity, frequency, duration, quit date if applicable]
• Diet Pattern: [Meal timing, predominant tastes (rasa), hydration, restrictions]
• Sleep Schedule: [Bedtime/wake time, quality, disruptions]
• Activity Level: [Baseline activity/exercise; yoga/pranayama practice]
• Bowel/Urinary Habits: [Baseline frequency and characteristics]
• Current Stressors: [Psychosocial/financial/environmental factors]
• Dinacharya/Seasonal Factors: [Routine disruptions; seasonal exposures] (Include when relevant to inpatient plan)

Review of Systems

[System-based review] (Include full ROS or focused ROS relevant to presentation; if facility policy permits, conclude with "All other systems reviewed and negative"; if ROS not performed or limited, state the reason)

Physical Examination

General and Systems Examination

• General: [Appearance, distress level, orientation]
• Vital Signs: [Time obtained; HR, BP, RR, Temp, SpO₂; orthostatics if indicated; height, weight, BMI]
• Cardiovascular: [Pertinent findings]
• Respiratory: [Pertinent findings]
• Abdominal: [Inspection, palpation, percussion, auscultation findings]
• Neurological: [Mental status, focal deficits, gait if assessed]
• Musculoskeletal: [Joint/soft tissue findings, tenderness, ROM]
• Skin: [Integrity, rashes, wounds; baseline skin condition and heat intolerance/syncope/dehydration history if Panchakarma planned]
• Other Systems: [Findings as relevant to presentation]

Ayurvedic Clinical Examination

Aṣṭavidha Parīkṣā (Eightfold Examination):

• Nādi (Pulse): [Character per institutional convention] (Record assessor/method when relevant)
• Mūtra (Urine): [Frequency, quality, notable features]
• Mala (Stool): [Frequency, consistency; constipation/diarrhea qualifiers]
• Jihvā (Tongue): [Coating, color, dryness, fissures]
• Śabda (Voice/Speech): [Quality, abnormalities]
• Sparśa (Touch/Skin): [Temperature, texture]
• Dṛk (Eyes/Vision): [Findings]
• Ākṛti (Build/Appearance): [Body habitus, posture]

Daśavidha Parīkṣā (Tenfold Examination): (Do not auto-fill Prakṛti or Vikṛti; use "Not assessed" or "Deferred" with reason if not evaluated; record assessor and method when relevant)

• Prakṛti (Constitution): [Findings / Not assessed / Deferred: reason]
• Vikṛti (Current imbalance): [Findings / Not assessed / Deferred: reason]
• Sāra (Tissue excellence): [Findings / Not assessed]
• Saṃhanana (Compactness): [Findings / Not assessed]
• Pramāṇa (Anthropometry): [Measurements / Not assessed]
• Sātmya (Habituation/Tolerance): [Diet/lifestyle tolerance]
• Sattva (Psychological strength): [Findings / Not assessed]
• Āhāra-śakti (Digestive capacity): [Findings / Not assessed]
• Vyāyāma-śakti (Exercise capacity): [Findings / Not assessed]
• Vaya (Age category): [Findings]

Focused Ayurvedic Assessments: [Agni type; signs of āma; Koṣṭha classification; Rogi bala/Roga bala] (Include only if directly informing the plan)

Diagnostics and Data Review

• Outside Records Reviewed: [Source, date, key findings]
• Admission Labs/Imaging: [Date/time; test name and key results with abnormal values highlighted; brief clinical interpretation]
• Standardized Ayurveda Morbidity Codes: [Codes with textual diagnoses] (If facility uses them)
• Pending/Ordered Studies: [Test name; clinical indication; status: ordered / pending / expected time]

Assessment

(List problems in descending order of severity/urgency; for each include working diagnosis using Ayurvedic and/or biomedical terms, key supporting evidence, differential diagnoses when uncertain, and severity/risk flags; include samprāpti statement when it changes management; document doṣa predominance and stage only if it drives therapy selection; restate inpatient appropriateness rationale if not already detailed in HPI)

• Problem 1: [Working diagnosis] — [Key evidence; differentials if applicable; severity/risk; samprāpti/doṣa notes if management-altering]
• Problem 2: [Working diagnosis] — [Key evidence; differentials if applicable; severity/risk]

Plan

(Problem-oriented format; include only relevant elements for each problem; omit non-applicable items)

Problem 1: [Diagnosis]

• Goals: [Measurable admission targets: symptom improvement, procedure completion, functional restoration]
• Chikitsā Strategy: [Śamana vs. Śodhana rationale and sequence; stop/hold criteria]
• Medications: [Ayurvedic and conventional medications with dose, route, timing, anupāna, duration; PRNs with indications; interaction considerations]
• Procedures/Therapies: [Panchakarma or related therapy; frequency, duration, materials; pre-procedure requirements; post-procedure monitoring; complication surveillance]
• Diet: [Diet type/texture; restrictions; pathya/apathya; meal timing; hydration plan; saṃsarjana krama progression if applicable]
• Activity and Regimen: [Activity level; physiotherapy; supervised yoga/prānāyāma; heat/cold restrictions; sleep recommendations]
• Monitoring: [Vitals frequency; orthostatics if dehydration risk; I/O; bowel tracking; symptom scales; lab monitoring schedule]
• Safety: [Fall precautions; pressure injury prevention; VTE prophylaxis per policy; infection control considerations]
• Consults: [Internal Ayurveda specialties; triggers for conventional medicine consultation]
• Patient Education and Consent: [Risks/benefits/alternatives discussed; consent obtained, by whom, capacity; if deferred, reason and plan]
• Discharge Planning: [Anticipated length of stay; discharge criteria; follow-up needs; high-level home regimen outline]

Problem 2: [Diagnosis]

• Goals: [Measurable targets]
• Treatment Strategy: [Relevant elements from above categories as applicable]

Orders Summary

(Consolidated operational summary for nursing and pharmacy execution)

• Medications (Scheduled): [Name, dose, route, frequency, timing, anupāna; hold parameters]
• Medications (PRN): [Name, dose, route, frequency; indication; hold parameters]
• Diet Order: [Diet type; procedure-linked progression; restrictions]
• Activity/Precautions: [Activity level; fall precautions; heat/cold restrictions]
• Nursing Monitoring: [Vitals frequency; I/O; bowel charting; symptom scales; skin checks]
• Labs/Diagnostics: [Test name; timing/frequency; special handling]
• Therapies Schedule: [Procedure name; frequency; pre/post documentation requirements]
• Consults: [Service; urgency; reason]

Signature

Author Signature/Credentials: [Name, degrees, role] Date/Time: [Date and time of signature]

(For any missing information throughout the note, use explicit language such as "Unknown," "Not assessed," or "Deferred due to [reason]" rather than leaving sections blank or inserting placeholder normal findings that were not examined)