Hospital Admission Note

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

Date/Time Note Signed: [Date and time note signed]

Author: [Author name and role]

Attending of Record: [Attending name]

Service/Team: [Admitting service/team]

Location: [Current location and transfer path]

Admission Status: [inpatient / observation]

Patient Name: [Patient full name]

MRN: [Medical record number]

DOB/Age: [Date of birth and age]

Sex: [Sex]

Weight: [Weight with units]

Source of History: [Source(s) and reliability] (Specify whether patient, family, EMS, or outside records provided history; comment on reliability if limited.)

Interpreter Used: [Language and modality] (Include only if interpreter was used.)

Isolation Status: [None / Contact / Droplet / Airborne / Enhanced / Pending] (Include rationale if applicable.)

Brief Summary

[One-sentence admission summary] (Single sentence capturing age, sex, decision-relevant comorbidities, reason for admission, and current acuity. Use hedging language when diagnosis is uncertain.)

Chief Concern

[Primary reason for admission] (Include concise symptom description. Add a brief patient or family quote only if it adds clinical clarity. If patient cannot provide history, document why and cite alternate source.)

History of Present Illness

[Narrative timeline and symptom characterization] (Describe onset, progression, triggers, severity, associated symptoms, relevant risk factors and exposures, and pertinent negatives that meaningfully affect the differential. Do not document negatives for questions not asked.)

Baseline Status: [Baseline function and supports] (Include mobility, ADLs, cognition, home oxygen, baseline mental status, and home supports with recent changes.)

Pre-Hospital/ED Course: [Key interventions and responses] (Summarize pre-hospital and ED therapies with responses; include key diagnostic results that informed the admission decision.)

Pertinent ROS: [Focused review of systems] (List positives and high-value negatives relevant to the presenting problem. Do not state "all other systems negative" unless a comprehensive review was performed.)

(If history is limited due to clinical status, explicitly state the limitation and list supplementary sources used.)

Past History

Past Medical History: [Active and major historical diagnoses] (Include relevant complications and baseline severity.)

Past Surgical/Procedural History: [Surgeries, procedures, implanted devices] (Include dates if known.)

Home Medications: [Medication list with source] (Include dose/route/frequency if available; note adherence and last dose when clinically important. If reconciliation is incomplete, state this and document plan to complete.)

Allergies: [Allergen(s) and reaction(s)] (Specify reaction type and severity. If reaction type unknown, document "Reaction unknown (reported)." If allergy status unavailable, document gap and plan to verify.)

Social History: [Living situation, supports, tobacco/alcohol/substance use, occupation, safety concerns] (Include elements relevant to care or disposition.)

Family History: [Relevant conditions] (Include only conditions that change risk stratification or workup for this admission.)

Objective

Vital Signs: [Initial and most recent vitals] (Highlight abnormalities, instability, or trends.)

Physical Exam:

• [General appearance and mental status]
• [HEENT]
• [Cardiovascular]
• [Respiratory]
• [Abdomen]
• [Extremities]
• [Neurologic]
• [Skin]
• [Other systems as indicated]

(Problem-focused; document exam limitations when applicable. Include or omit systems based on clinical relevance.)

Diagnostics Reviewed:

• Labs: [Key abnormal values and critical normals with context] (Include trends from baseline; avoid pasting full panels.)
• Imaging: [Summarized impressions] (Note clinician interpretation if it drove decisions.)
• EKG: [Rate, rhythm, ischemic changes, intervals as relevant]
• Microbiology: [Cultures sent/pending, rapid results, isolation implications]
• Other studies: [ABG, POCUS, etc.]

Lines/Drains/Airways: [Type, location, date placed]

Pending: [List of pending studies with expected timelines]

Assessment

[Assessment summary] (1–3 sentences integrating the clinical story, key objective findings, and working diagnosis(es).)

Problem List (prioritized by acuity):

• [Problem 1]: [Brief assessment] (If diagnostic uncertainty exists, include focused differential with supporting and refuting evidence.)
• [Problem 2]: [Brief assessment]
• [Additional problems as needed]

Plan

(Organize by problem. Address diagnostics, therapies, fluids, monitoring, and consults as relevant to each problem.)

[Problem 1]: [Diagnosis or clinical impression]

• Dx: [Diagnostics ordered and rationale]
• Tx: [Medications and procedures with dose/route/frequency] (Include indication, duration or stop criteria, and safety parameters.)
• IVF: [Type, rate, indication, reassessment plan] (Document balancing rationale if fluid-restricted.)
• Monitoring: [Parameters, frequency, action thresholds]
• Consults: [Services requested with rationale]

[Problem 2]: [Diagnosis or clinical impression]

• Dx: [Diagnostics]
• Tx: [Therapies]
• IVF: [Fluids plan]
• Monitoring: [Monitoring plan]
• Consults: [Consults]

(Repeat for additional problems as needed.)

Admission Orders Summary

• Level of Care: [ICU / stepdown / floor; telemetry; continuous pulse oximetry]
• Code Status: [Code status, surrogate decision-maker, goals-of-care discussion status]
• Diet: [Diet order; aspiration precautions; nutrition consult if needed]
• Activity: [Activity order; PT/OT needs; fall precautions if indicated]
• Prophylaxis: [VTE prophylaxis; GI prophylaxis only if indicated; pressure injury prevention if high risk]
• Monitoring: [Vitals frequency, neuro checks, glucose checks, I/O, daily weights as applicable]
• Home Medications: [Medications continued and held with rationale] (Highlight anticoagulants, antihypertensives, and diabetes medications.)
• Consults: [Social work/case management if disposition barriers anticipated]
• Isolation: [Isolation status and rationale; pending tests that may change precautions]

Anticipated Course / Disposition

[Expected trajectory and estimated length of stay] (List discharge milestones: oxygen needs, oral intake, renal stability, etc. Note anticipated destination and foreseeable barriers. Distinguish anticipated from confirmed items.)

Communication Plan

Primary Contact: [Name, relationship, decision-maker status, callback number]

Discussion Summary: [Topics discussed: diagnostic uncertainty, risks/benefits, expected course]

Next Update: [Communication cadence and next planned update]

Consent: [Consent discussions for procedures, transfusion, or high-risk therapies]

(If no communication has occurred, document plan and timeline for family contact.)

Handoff / Contingencies

(Include when patient is unstable, results are pending overnight, or escalation thresholds need to be explicit. Omit if not applicable.)

• Illness severity: [stable / watcher / unstable]
• Action list: [Tasks with timing and thresholds]
• Pending results: [Results expected and response instructions]
• Anticipatory guidance: [Instructions if clinical status changes]