Admission and progress note examples for a private admission

The admission note template and the progress note template in aurii each carry a worked example as a synthetic record, on the admission note template and progress note template pages. The admission note runs in the order the assessment happens and the progress note runs in SOAP order. Both are among the app's starter templates, shaped to the practice at Setup, and both download as blank A4 PDFs with the section headings only. aurii drafts both from a bedside capture on the phone for the specialist to edit and sign.

The admission note template in aurii runs in the order the assessment happens.

The worked example on the admission note template page is a synthetic record of a community-acquired pneumonia admission. It carries a background of standing diagnoses and home circumstances, a short history of breathlessness and productive cough, findings at the right base on examination, admission bloods with the chest film pending, the working diagnosis, and a plan of intravenous antibiotics, oxygen as required, daily review and the chest film to be chased. The full record is on the admission note template page.

The progress note template runs in SOAP order.

The worked example on the progress note template page is a separate synthetic record, taken from later in a pneumonia admission. It carries overnight events with oxygen weaned to room air, a settling cough with the patient mobilising, examination on room air, an inflammatory marker falling against the admission value with the white cells normalised, an impression of a course responding to intravenous antibiotics, and a plan of the switch to oral antibiotics, a repeat chest film, physiotherapy review and discharge if the trend holds. The two examples are separate synthetic records. The full record is on the progress note template page.

Where the specialist reviews with the team on a round, the ward round note runs status, overnight events, focused examination and today's tasks. Where the specialist reviews alone, the progress note is the record. AI documentation on ward rounds sets out the round itself.

aurii drafts the discharge summary from the admission documentation supplied to it. The discharge note runs status at discharge, final diagnoses, hospital course summary, investigations pending, discharge medications, follow-up arrangements and patient instructions, and the clinician checks the medication list line by line against the chart before signing. The GP copy goes by Medical Objects. The discharge note and the GP discharge summary are the templates, and Writing a discharge summary with AI documentation sets out timing and content.

The Medical Board of Australia's Good Medical Practice code sets out records that are accurate, up to date, factual, objective and legible, made at the time of the events or as soon as possible afterwards, that record the clinical history, findings, investigations, information given to the patient, medication and other management, in a form other practitioners can understand. The admission note template carries the history, findings and investigations elements. Each progress note carries the management element, and the signature carries the clinician's name and the time it was applied.

The National Safety and Quality Health Service Standards, which private hospitals are accredited against, set the hospital-side requirements. The Clinical Governance Standard requires healthcare records systems that make the record available at the point of care and support the workforce to keep accurate and complete records. The Comprehensive Care Standard requires screening and clinical assessment at the start of the episode and a documented comprehensive care plan, and the admission note is where that assessment is recorded. The Communicating for Safety Standard requires critical information, alerts and risks to be documented and communicated at transitions of care, which the plan line of each progress note and the handover record carry.

The draft, the specialist's edit and the signed version of every note stay on the record in the audit trail. Clinical records as legal documents sets out the record in a complaint or a claim.

The specialist captures the admission review on the phone at the bedside, by dictation or by ambient capture of the review with the patient. aurii drafts the admission note into the template headings against the patient record. Pathology and imaging are ordered from the patient record on the round, and each order shows Draft, Ready to send, Sent or Received on the record. The specialist reads the draft, edits it and signs it.

On each day that follows, the same capture at the bedside drafts the progress note into the progress note template's headings. Results received since the last note sit on the same patient timeline as the note. The impression and plan lines are drafted from what the specialist said at the bed. Billing items are confirmed at the bedside and recorded against the episode for the specialist to sign.

Processing runs in Australia only. Capture, drafting, orders and billing are set out on the product page.

Start from the admission note template on the day of admission and the progress note template on every day after. The specialist edits each draft in the note before signing.