Admission note template
The first inpatient note of the stay, from the background history to the plan.
- Background medical history
- Standing diagnoses, past surgery, medications, allergies.
- Presenting complaint
- One line, with the timeline.
- History of presenting illness
- Symptoms, duration, severity, earlier episodes.
- Examination
- Vitals, then by system.
- Investigations
- Bloods, imaging, ECG, microbiology on admission.
- Impression
- Working diagnosis and differentials.
- Plan
- Investigations to chase, treatment started, monitoring, consults, disposition.
Worked examples
Admission note · respiratory admission Lombardi, Carla · 67F · Synthetic patient
Background HTN, T2DM. Independent at home. Non-smoker. Presenting complaint 3 days of increasing SOB and productive cough. Examination T 37.4, HR 92, BP 134/80, RR 20, SpO2 94% RA. R basal creps, chest otherwise clear. Investigations CRP 86, WCC 12.4. CXR: right lower lobe consolidation. Impression Community-acquired pneumonia, right lower lobe. SMART-COP 1, low severity. Plan PO amoxicillin 1 g TDS and PO doxycycline 100 mg BD. O2 to keep SpO2 above 92%. Sputum MCS.
Admission note · cardiology admission Wilson, Graham · 79M · Synthetic patient
Background Ischaemic cardiomyopathy, LVEF 35%. CKD stage 3. Presenting complaint 5 days of bilateral leg swelling and orthopnoea. Examination BP 148/86, HR 96 irregular. JVP raised. Pitting oedema to mid-shin. Investigations Cr 142, K 4.6, NT-proBNP 4,200. ECG: AF, new. CXR: upper lobe diversion, small bilateral effusions. Impression Decompensated heart failure, precipitated by new AF. Plan IV furosemide 80 mg BD. Daily weights, fluid balance chart, fluid restriction 1.5 L. Metoprolol for rate control. Anticoagulate: apixaban 5 mg BD (CHA2DS2-VASc 4). EUC in the morning.
