An admission note is written for patients to be admitted to a hospital.[1] It is possible for multiple admission notes to be written for a single patient.[2]
Admission notes are used by healthcare payors to determine billing; doctors 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.
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 includes:
Not every admission note explicitly discusses every item listed below, however, the ideal admission note would include:
Typically one sentence including
Health or cause of death for:
In medicine, a social history is a portion of the admission note addressing familial, occupational, and recreational aspects of the patient's personal life that have the potential to be clinically significant.
Physical examination or clinical examination is the process by which a health care provider investigates the body of a patient for signs of disease.
eg: electrolytes, arterial blood gases, liver function tests, etc
Assessment includes a discussion of the differential diagnosis and supporting history and exam findings.
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