Inpatient Admission Note (Oral and Maxillofacial Surgery)

Date/Time of Service: [Date and time]
Hospital Day: [HD#]
Location: [ED / ICU / Floor]
Admitting Service: [OMS Primary / OMS Consult]
Attending: [Attending name, credentials]
Author: [Author name, credentials]
Patient Name: [Full name]
MRN: [Medical record number]
DOB/Age: [DOB] / [Age]
Sex: [Sex]
Allergies: [Medication allergens with reaction and severity] (If unknown at time of admission, state: "Allergies unknown; verification pending" and add follow-up action in Plan.)

Source of History: [Patient / Family / EMS / Outside records / Other] (Specify interpreter use with language if applicable. State any limitations such as intubation, intoxication, AMS, trismus, pain, or sedation. Document external records reviewed.)

Reason for Admission: [Brief statement of medical necessity requiring inpatient-level care] (Examples: airway monitoring/risk, need for IV antibiotics, operative management, inability to tolerate oral intake, close neuro/vision monitoring.)

Clinical Summary

[One sentence: age, relevant PMH, primary diagnosis or mechanism, key severity features, and immediate plan]

Chief Complaint

"[Patient-stated complaint]" (If patient cannot report, provide concise clinically assigned complaint.)

History of Present Illness

[Narrative summary beginning with chief complaint and timeline] (Include: onset with specific dates/times; prior care received including antibiotics, prior I&D, outside imaging, transfers; airway symptoms such as dyspnea, stridor, voice change, drooling, inability to lie flat, rapidly progressive swelling; swallowing difficulties including dysphagia, odynophagia, PO intolerance; neuro/vision symptoms including vision changes, diplopia, facial numbness, malocclusion, AMS; systemic infection signs including fevers, rigors, tachycardia, hypotension; pain characterization; relevant exposures such as anticoagulants, substances, tetanus status for trauma, pregnancy if applicable. When information cannot be obtained, specify reason and document unknowns explicitly with follow-up in Plan.)

(If trauma) [Mechanism, LOC or amnesia, time since injury, c-spine status, bleeding concerns, dental trauma details including avulsed/luxated teeth, bite changes, paresthesia distribution]

(If odontogenic/deep space infection) [Suspected source tooth or region, dental pain history, swelling progression, trismus onset and severity, MIO if known, floor-of-mouth elevation, neck involvement, prior antibiotic trials with adherence and failures]

Review of Systems

[Targeted ROS findings] (List positives first, then pertinent negatives. Focus on constitutional, airway/respiratory, GI including PO tolerance, neurologic, vision/eye, cardiovascular including syncope for trauma, bleeding/bruising if anticoagulated. If ROS cannot be obtained, state: "Unable to obtain ROS due to [reason]." Omit section entirely if patient is intubated or otherwise unable to participate and no surrogate is available.)

Past Medical History

[Conditions affecting perioperative, anesthesia, or infection risk] (Prioritize: diabetes with control status, immunosuppression or steroid use, OSA with CPAP status, CAD/CHF, CKD/liver disease, seizure disorder, bleeding/clotting disorders.)

Past Surgical History

[Relevant surgical history] (Prioritize: head/neck surgeries, facial fracture repairs, tracheostomy history, prior difficult intubation or airway complications.)

Medications

[Home medications with doses and last taken time when relevant] (Emphasize: anticoagulants/antiplatelets, insulin/oral hypoglycemics, steroids, immunosuppressants, chronic opioids/benzodiazepines.)

Medication Reconciliation: [Completed / Partially completed / Pending] (If pending, specify what remains to be verified.)

Social History

[Relevant social history] (Include when applicable: tobacco/vape use, alcohol use with last drink and withdrawal risk, recreational drug use relevant to anesthesia or healing, housing/support and ability to attend follow-up, safety concerns if assault or domestic violence.)

Family History

[Relevant family history] (Include only if directly relevant: bleeding disorders, malignant hyperthermia, anesthesia complications. Omit section if no pertinent family history.)

Physical Examination

Vitals: [BP, HR, RR, Temp, SpO2, Weight/BMI if relevant] (Include temperature trend if febrile.)

General: [Appearance, distress level, toxicity, ability to speak full sentences, ability to lie flat]

Airway: [Voice quality, stridor present/absent, work of breathing, secretions handling, drooling present/absent, mouth opening with MIO in mm, tongue position, floor-of-mouth elevation, uvular deviation if relevant] (If intubated or trached: document tube type/size, depth, and note airway contingency plan exists. This subsection is mandatory for all OMS admissions.)

Head/Face: [Facial symmetry, swelling/induration/erythema with location, ecchymosis, palpable step-offs, crepitus or subcutaneous emphysema, tenderness, lacerations with location and size]

Eyes: (Mandatory when orbital or midface trauma is possible or reported.)

• Visual acuity: [OD / OS] (Note if unable to assess and why.)
• Pupils: [Size, reactivity, APD status]
• Extraocular movements: [Full / Limited with description, pain present/absent]
• Diplopia: [Present / Absent]
• Globe position: [Normal / Enophthalmos / Proptosis]
• Conjunctiva: [Subconjunctival hemorrhage, chemosis present/absent]

(If eye exam limited, state limitation and document escalation plan in Plan.)

Nose: [External deformity/edema, septal hematoma present/absent if trauma suspected, CSF rhinorrhea concern if skull base injury possible]

Oral Cavity: [Dentition status, fractured/loose teeth, mucosal lacerations, gingival and floor-of-mouth induration/fluctuance/purulence, tongue elevation, oropharynx and uvula position, salivary flow if relevant]

Occlusion and Mandible/Maxilla: [Occlusion description: baseline per patient vs malocclusion with type, mandibular stability, segment mobility, open bite/crossbite/midline deviation, TMJ tenderness and ROM] (Mandatory for trauma; include for severe infection.)

Cranial Nerves: [CN II gross vision, CN V sensation by division V1/V2/V3 with paresthesia distribution if present, CN VII motor function, other focal deficits] (Mandatory for trauma; recommended for severe infection.)

Neck: [Swelling, induration, fluctuance, tenderness, tracheal deviation, ROM, lymphadenopathy, c-spine precautions status if trauma]

Cardiopulmonary/Abdominal/Extremities: [Brief exam relevant to sepsis evaluation, operative clearance, or trauma survey] (Abbreviated format acceptable if noncontributory.)

Diagnostics

Labs

[Relevant laboratory values] (Include: CBC with differential, BMP/CMP, lactate if sepsis concern, CRP if used, coagulation studies if indicated, culture status including blood cultures obtained and wound/OR cultures planned.)

Imaging

[Study modality, anatomic region, contrast status, date/time] (State whether independently reviewed vs radiology report only. Summarize clinically relevant findings tied to the plan. Example: "CT maxillofacial without contrast reviewed by me: [key findings]. Radiology report also reviewed.")

External Records

[Outside ED notes, EMS report, prior imaging, dental records reviewed] (Note if expected records could not be obtained. Omit subsection if no external records applicable.)

Assessment

(Problem-oriented format; list in order of clinical severity. For each problem: working diagnosis or differential, severity and complications, key supporting evidence, and rationale for management decisions. Document diagnostic uncertainty and plan to resolve.)

[Problem 1]: [Working diagnosis or differential]

• Severity/Complications: [Airway risk, sepsis, vision risk, open fracture, etc.]
• Supporting Evidence: [Key findings from history, exam, labs, imaging]
• Management Rationale: [Why inpatient level, OR vs medical management, ICU vs floor]

[Problem 2]: [Working diagnosis or differential]

• [Details as above]

(Add additional problems as applicable.)

Plan

Airway Management

• Current status: [Airway status with supporting exam findings]
• Monitoring: [Level of care and monitoring frequency]
• NPO: [Status and timing]
• Anesthesia: [Involvement and timing if high-risk]
• Escalation: [Criteria and backup airway plan]
• Steroids: [Only if explicitly decided, with rationale]

(Include on nearly all OMS admissions; mandatory for deep infections and significant facial trauma.)

Infection Management

• Source control: [Bedside vs OR I&D, extractions, drains, cultures]
• Antibiotics: [Empiric regimen with agents, doses, start time, rationale]
• De-escalation: [Plan based on cultures and clinical improvement]
• Duration: [Estimated duration of therapy]
• Follow-up imaging: [Criteria for repeat imaging]
• Disposition criteria: [Criteria for discharge]

(Include for odontogenic or deep space infections. Omit if not applicable.)

Facial Trauma / Fractures

• Injury inventory: [List of injuries]
• Operative plan: [Operative vs nonoperative with timing and rationale]
• Planned procedures: [Specific procedures]
• Antibiotics: [If indicated]
• Tetanus: [Update plan]
• Precautions: [Sinus precautions if midface involved, diet restrictions]
• Oral hygiene: [Mouth care plan]

(Include for trauma admissions. Omit if not applicable.)

Orbital / Eye

• Baseline exam: [Reference eye exam findings above]
• Ophthalmology: [Consult timing: emergent / urgent / outpatient with criteria]
• Monitoring: [Diplopia and vision monitoring plan with escalation triggers]

(Include when orbital involvement present. Omit if not applicable.)

Pain Control

• Analgesia: [Multimodal plan with agents]
• Antiemetics: [Plan] (Note: vomiting can worsen airway and ocular risks.)
• Bowel regimen: [If opioids used]

VTE Prophylaxis / Anticoagulation

• Prophylaxis: [Mechanical and/or chemical with timing relative to OR]
• Home anticoagulants: [Management plan; reversal if applicable]

Nutrition / Hydration

• Diet: [Diet order]
• Fluids: [IV fluid plan]
• Enteral access: [If prolonged NPO anticipated]
• Diabetes: [Nutrition considerations if applicable]

Comorbidity Management

• [Active comorbidity management as applicable: diabetes control, immunosuppression, OSA precautions with CPAP, substance withdrawal prophylaxis]

(Omit section if no active comorbidities requiring management.)

Disposition and Coordination

• Primary service: [Service responsibility]
• Consults: [Consulting services with indications]
• OR status: [Booking status and timing]
• Postoperative destination: [ICU / Floor / Home]
• Follow-up: [Clinic timing, suture removal, drain management, dental follow-up]

Consent and Communication

• Procedure consent: [If operative plan established: risks, benefits, alternatives discussed; patient questions addressed]
• Family communication: [Details if applicable]
• Inter-service discussions: [Key discussions affecting management, e.g., anesthesia airway plan]
• Decision-making capacity: [If patient lacks capacity: surrogate and basis]

(Omit items not applicable to current admission.)

Safety instructions: For critical items—airway status, allergies, medications—explicitly state when information is pending or could not be obtained and include follow-up action in Plan. For sections not applicable, omit the entire section rather than leaving empty placeholders. Never infer airway stability, eye safety, normal occlusion, or absence of neurologic deficits—these must be explicitly examined and documented, or limitations stated with plan to address.