An admission note, frequently referred to as a History and Physical (H&P), is the foundational document created when a patient is formally admitted to a hospital service. This comprehensive report establishes the patient’s baseline status, providing a detailed snapshot of their health prior to treatment, and serves as the primary vehicle for clear communication among the care team. Furthermore, the admission note is a legal record that justifies the need for inpatient care and guides subsequent clinical decisions throughout the hospital stay.
The Foundational Structure
The initial segments of the admission note are dedicated to the systematic collection of subjective and objective data, forming the patient’s comprehensive medical story. This process begins with the Chief Complaint (CC), the primary reason for admission, often captured in the patient’s own words. The History of Present Illness (HPI) then expands on this complaint, presenting a chronological account of the symptom’s evolution from its onset. This section should incorporate relevant details from the patient’s past, social, and family history that may be contributing to the current problem.
Following the HPI, the note transitions to a structured review of the patient’s background and systems. The Past Medical History (PMH) lists all previous diagnoses, surgical history, and current medications, including dosage and frequency. A thorough Review of Systems (ROS) systematically inquires about symptoms relevant to their overall health. Documentation should be concise, often utilizing bullet points or negative statements to efficiently capture the absence of symptoms, such as “denies fever, chills, or night sweats”.
The objective data collection culminates in the Physical Examination (PE), a structured assessment of the patient’s current clinical status. This begins with recording the patient’s vital signs, including temperature, heart rate, blood pressure, and oxygen saturation, as these are indicators of systemic stability. The remainder of the PE is performed systematically, often proceeding from head-to-toe, with findings organized by organ system (e.g., Cardiac, Pulmonary, Abdominal). It is important to document not only abnormal findings but also pertinent normal findings to demonstrate a complete examination.
Crafting the Assessment
The Assessment section represents the shift from data collection to clinical synthesis, transforming findings into a set of working diagnoses. This part of the note should begin with a concise summary statement, often called the “Sponsor Sentence,” which identifies the patient by age, gender, relevant past medical history, and the primary reason for admission. For example, this statement might describe a “65-year-old female with a history of hypertension presenting with three days of progressively worsening shortness of breath”.
The core of the Assessment is the prioritized Problem List, where the clinician organizes all active issues affecting the patient, listing the most acute problems first. Each distinct problem must be supported by a concise analysis that connects the collected data to a working diagnosis or a differential diagnosis. For instance, for a problem like “Acute Kidney Injury,” the assessment should reference specific supporting data, such as a recent elevation in serum creatinine or evidence of dehydration on physical exam.
The assessment should clearly state the most likely diagnosis for each problem, using terms like “Probable,” “Possible,” or “Suspected” when certainty is not yet established. It is also helpful to combine related issues where possible, using a systems-based approach to group problems that share a common etiology or treatment strategy. This critical thinking phase articulates a clinical hypothesis, laying the groundwork for the subsequent management plan. The assessment justifies the admission and demonstrates the clinician’s understanding of the patient’s clinical picture.
Developing the Multidisciplinary Plan
The Plan section is the action-oriented component of the admission note, translating diagnostic assessments into concrete steps for patient management. The structure of the Plan must directly mirror the prioritized Problem List established in the Assessment, ensuring a clear link between the identified issue and the proposed treatment. This organization often utilizes a systems-based approach, detailing interventions for cardiovascular, pulmonary, or gastrointestinal problems sequentially.
For each problem, the plan should be broken down into distinct categories to guide the multidisciplinary team. The Diagnostics subsection outlines necessary workup, specifying required laboratory tests, such as complete blood counts or cardiac enzymes, and imaging studies, like chest X-rays or CT scans. The Therapeutics subsection details all orders related to treatment, including medication prescriptions, intravenous fluid administration, and specific procedures. This section must be precise, noting the dose, route, and frequency for all pharmacological interventions.
In addition to immediate treatment, the plan must address ongoing patient care and future considerations. The Monitoring component specifies how the patient’s condition will be tracked, such as serial vital sign checks, strict intake and output tracking, or continuous telemetry monitoring. Consultations should be explicitly requested here, naming the specialty and the specific question being asked. Finally, Disposition planning should begin early, outlining the anticipated trajectory of the hospital stay and the expected needs for discharge, such as physical therapy or transfer to a skilled nursing facility.