Surgical Admission H&P (Inpatient)

Date/Time of Encounter: [Date and time]

Date/Time of Exam: [Date and time]

Admitting Service: [Surgical service name]

Admission Source: [ED / transfer / direct admit / postop transfer]

Primary Reason for Admission: [Primary reason]

Planned Procedure: [Procedure name with laterality/site] (Write "None - nonoperative management" if no surgery planned)

History Source: [patient / family / EMS / outside records / other] (Note interpreter use and language if applicable)

H&P Update

(Include this section only if a recent H&P exists from clinic, ED, or outside facility; otherwise omit entirely and proceed with a full H&P below.)

• Referenced prior H&P: [Author, setting, date/time]
• Records reviewed: [List specific documents or sources reviewed]
• Interval change statement: [State "no interval change" or specify changes in symptoms, exam, vitals, labs, imaging, medications, or clinical status since prior H&P]
• Current exam performed today: [Key findings from today's exam]

Chief Complaint

[Chief complaint] (Use a direct patient quote when it adds clarity)

History of Present Illness

[Opening summary: age, relevant background, presenting problem, acuity. Symptom chronology including onset, duration, progression, quality, severity, location, radiation, and associated symptoms. Oral intake status, NPO timing with last solid and liquid intake. Bowel function including last BM/flatus and any changes.]

[Prior episodes and workup if relevant. Interventions to date including ED or outside therapies, fluids, antibiotics, analgesia, tubes/lines placed. Outside facility course if transfer with key vitals, labs, imaging, and treatments given. Anticoagulant/antiplatelet use with agent, indication, and last dose if applicable.]

[Reason for surgical admission: operative indication vs trial of nonoperative management. Pending decisions, tests, or consults.] (If history is limited or unobtainable, briefly explain the limitation and sources used.)

Past History

Past Medical History: [Relevant diagnoses] (Emphasize conditions affecting operative risk, wound healing/infection risk, and bleeding/clotting risk. Document "No known PMH" or "PMH unknown" explicitly if applicable.)

Past Surgical History: [Prior operations and procedures] (Include prior abdominal surgeries, vascular access, implants/devices, and anesthesia complications such as difficult airway, malignant hyperthermia, or severe PONV if known.)

Bleeding/Clotting History: [Personal history of VTE, bleeding complications, transfusion reactions; current anticoagulants/antiplatelets with indication]

Medications

[Home medications with name, dose, route, frequency]

High-impact perioperative medications: [Anticoagulants/antiplatelets with indication and last dose; insulin/diabetes agents; chronic opioids/benzodiazepines; steroids with dose/duration; immunosuppressants] (If list is incomplete, document "best available" and sources checked.)

Allergies

[Allergies with reaction type] (Document NKDA if none. If unable to obtain, write "Allergies unknown" with explanation. Always include this section.)

Social History

• Living situation: [Home setting and caregiver support]
• Functional status: [Baseline mobility, ADL status, ambulation aids, fall history]
• Substance use: [Tobacco, alcohol, and other substances] (Note withdrawal risk if applicable)
• Code status: [Code status and surrogate decision-maker if addressed] (Document "to be discussed" if not yet addressed)

Family History

[Relevant familial conditions affecting surgical/perioperative risk: bleeding disorders, malignant hyperthermia, VTE, premature CAD] (Omit this section if noncontributory and time-critical.)

Review of Systems

• Constitutional: [Fever, chills, weight loss, malaise]
• Cardiovascular: [Chest pain, palpitations, syncope, exercise tolerance]
• Respiratory: [Dyspnea, cough, orthopnea]
• Gastrointestinal: [Nausea, vomiting, abdominal pain, distension, obstipation/diarrhea, GI bleeding]
• Genitourinary: [Dysuria, retention, hematuria]
• Neurologic: [Headache, focal deficits, confusion]

(If ROS cannot be obtained, document why.)

Physical Exam

Vitals: [Temperature, heart rate, blood pressure, respiratory rate, SpO2, oxygen delivery if any]

General: [Appearance, mental status, degree of distress]

• Cardiovascular: [Rhythm, rate, perfusion]
• Respiratory: [Work of breathing, breath sounds, supplemental O2 requirement]
• Abdomen: [Inspection, tenderness, guarding/rebound, peritoneal signs, distension, masses, hernias]
• Skin/Soft Tissue: [Wounds/incisions, erythema, fluctuance, crepitus, pressure injuries]
• Extremities/Vascular: [Edema, pulses, capillary refill, limb ischemia signs]
• Neurologic: [Level of consciousness, focal deficits, spine exam] (Include if relevant)
• Rectal/GU/Pelvic: [Findings] (Include only when clinically indicated)

Lines/Drains/Tubes/Devices: [ETT, central lines, arterial line, NG/OG, Foley, ostomy, wound vac, drains with site/side, condition, and output if relevant]

(If exam is limited, state which elements could not be examined and why.)

Data

Labs: [Key results with dates: CBC, BMP/CMP, coagulation, lactate, UA, pregnancy test if applicable, type and screen] (Note pending labs)

Microbiology: [Cultures obtained and source] (Note if antibiotics started prior to cultures)

Imaging: [Modality, date, impression, pertinent findings] (State whether images were personally reviewed vs report only)

ECG/Cardiac: [ECG interpretation and cardiac testing results if obtained]

Assessment

[Synthesis paragraph: who the patient is, working diagnosis with key supporting data, reason for surgical admission including operative indication vs nonoperative trial]

1. [Problem 1: Primary surgical diagnosis] [Brief assessment, severity/acuity, key supporting findings]
2. [Problem 2: Physiologic derangement] [e.g., sepsis, hemorrhage, AKI, electrolyte abnormalities]
3. [Problem 3+: Comorbidities and perioperative risks] [Conditions requiring active management]

Plan

(Organize by problem number. For each problem include working diagnosis, differential if uncertainty exists, diagnostic plan, therapeutic plan, and reassessment triggers.)

1. [Problem 1: Primary surgical diagnosis]

   • Working diagnosis: [Diagnosis with brief justification; differential if uncertain]
   • Diagnostics: [Labs, imaging, consults, monitoring frequency]
   • Therapeutics: [Medications, fluids, procedures, bedside interventions]
   • Reassessment triggers: [Objective thresholds for escalation, OR, or ICU transfer]

2. [Problem 2: Physiologic derangement]

   • Diagnostics and monitoring: [Plan]
   • Therapeutics and targets: [Plan]
   • Reassessment triggers: [Thresholds]

3. [Problem 3+: Comorbidities/perioperative risks]

   • [Management steps and consultant coordination]

Operative Plan

(Include when surgery is planned or likely; otherwise omit.)

• Procedure: [Procedure name with laterality/site, indication, goals]
• Urgency: [emergent / urgent / elective during admission]
• Consent: [Obtained / pending] (Note reason if pending; document capacity/surrogate)
• NPO status: [Start time and last intake times]
• Antibiotic prophylaxis: [Agent, dose, timing]
• VTE prophylaxis: [Mechanical and/or pharmacologic; contraindications if any]
• Anticoagulation management: [Hold/reversal plan with agent-specific details]
• Blood availability: [Type and screen / crossmatch units]
• Pre-op optimization/consults: [Anesthesia, cardiology, medicine, others as needed]

Nonoperative Management Trial

(Include when nonoperative management chosen; otherwise omit.)

• Diagnostic strategy: [Serial exams, labs, imaging cadence with rationale]
• Therapeutic plan: [Antibiotics, bowel rest, diet advancement, analgesia]
• Failure criteria: [Objective triggers for operative intervention or ICU transfer]

General Admission Plan

• Level of care: [ICU / stepdown / telemetry / floor] (Rationale)
• Diet and fluids: [NPO / clear liquids / regular; IV fluid type and rate]
• Pain management: [Multimodal strategy; bowel regimen]
• VTE prophylaxis: [Mechanical and/or pharmacologic; contraindications]
• Glycemic management: [Targets and insulin strategy if applicable]
• Monitoring: [Vital frequency, urine output, drain outputs, lab trending with rationale]

Perioperative Risk and Optimization

(Include when surgery is planned or likely; otherwise omit.)

• Functional capacity: [METs estimate; ability to climb stairs/carry groceries]
• Cardiac risk: [Risk factors; indication for further testing or cardiology involvement] (Avoid "cleared" language)
• Pulmonary risk: [OSA, COPD/asthma optimization, incentive spirometry plan]
• Frailty/nutrition: [Optimization steps if applicable]