Admission note

An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.

Purpose

Admission notes document the reasons why a patient is being admitted for inpatient care to a hospital or other facility, the patient's baseline status, and the initial instructions for that patient's care. Health care professionals use them to record a patient's baseline status and may write additional on-service notes, progress notes (SOAP notes), preoperative notes, operative notes, postoperative notes, procedure notes, delivery notes, postpartum notes, and discharge notes. These notes constitute a large part of the medical record. Medical students often develop their clinical reasoning skills by writing admission notes. The traditional, rational definition of being admitted usually involves spending an overnight in the hospital. This definition is sometimes stretched in the U.S. medical billing industry, where hospital corporations may blur the definitions of "admission" and "observation" because of reimbursement rules under which healthcare payors pay less for the care if an "admission" was involved.

Components

An admission note may sometimes be incorrectly referred to as an HPI (history of present illness) or H and P (history and physical), which include only portions of an admission note.

An admission note can include the following sections:

Outline

Not every admission note explicitly discusses every item listed below, however, the ideal admission note would include:

Header

Patient identifying information (maybe located separately)

name

ID number

chart number

room number

date of birth

attending physician

sex

admission date

Date

Time

Service

Chief complaint (CC)

Typically one sentence including

age

race

sex

presenting complaint

example: "34 yo white male with right-sided weakness and slurred speech."

History of present illness (HPI)

statement of health status

detailed description of chief complaint

positive and negative symptoms related to the chief complaint based on the differential diagnosis the health care provider has developed.

emergency actions taken and patient responses if relevant

Allergies

first antigen and response

second antigen and response

etc.