How to Write an Admission Note

  1. General
    • Should be a story that is in the format of a UWorld Stem
  2. Subjective (Includes all the sections below)
    1. Identifying statement (Name, Age, Sex, PMH/PSH, CC)
      • Ex. Mr. Hill is a 25 y/o M w/PMH of Interstitial Lung Disease who presented to the ED on 09/04/2022 w/CC of shortness of breath. Relevantly, Mr. Hill follows w/PAC and was seen in their clinic yesterday where he was instructed to come to the ED.
    2. History of Present Illness (HPI)
      • Utilize OLDCARTS
        • Asking "When did you last feel normal", "Are you better, worse, or the same?", "What made you come in today?", and "What do you think this could be?" can often be helpful in eliciting an HPI
      • Ex. Today, he ℅ cough, wheezing, and sob that started a week ago that he says has been quickly worsening. He says feels he feels persistent chest tightness when trying to breath that hasn’t improved with his home albuterol inhaler. He states he has had some clear sputum production but not much. He denies aggravating factors, which includes exertion and laying flat.
    3. Meds/Allergies/FH/SH/Other relevant history/Code Status
      • You don't need to list every medication they have, but the important ones/ones relevant to the complaint need to be here
        • Call the spouse/SNF/Pharmacy if you must
      • Ex. He states he has been taking nitroglycerin at home daily as well as lasix 40mg QID for "his heart." He denies known allergies and states he has smoked for 20 years, 1 pack per day, but denies drinking alcohol or using illicit drugs. He states his dad had ILD and that he and his father used to work in a coal mine together until last month when his dad was sent to jail. Before this, he completed his ADLs without difficulty or assistance. He denies working currently and is a full code. His wife is his MPOA.
    4. ER Course
      • Vitals then PE, relevant or abnormal labs, diagnostic tests, ER assessment, ER interventions, and then "The medicine service was called to see the patient" or something like that.
      • Ex. In the ER, he was found to be afebrile, BP 120/70, HR 85, RR 18 w/SpO2 92% on room air. He was found to be mildly dyspneic by the ER staff with intermittent use of respiratory accessory muscles. Labs were relevant for a WBC of 16.0 and Glucose of 180. CXR was without focal consolidation. EKG showed normal sinus rhythm. PNA PCR was positive for H. Influenzae. He was given 80mg IV Lasix for presumed CHF, 2L Normal Saline for Sepsis, and Remdesivir for presumed COVID in the ER. The medicine service was then called for admission.
  3. 10 Point Review of Systems (ROS)
    • Constitutional: Denies fever, chills, fatigue, weight changes, night sweats
    • HEENT: Denies trauma, headache, dizziness, blurry vision, double vision, hearing loss, tinnitus, nasal congestion, sore throat, sinus pressure, ear pain change in voice, difficulty swallowing, eye pain, itchy eyes
    • Resp: Denies shortness of breath, cough, sputum production, wheezing, labored breathing, dyspnea on exertion, orthopnea, PND, hemoptysis, stridor
    • CV: Denies chest pain, palpitations, peripheral edema, syncope, diaphoresis, radiation, claudication
    • GI: Denies nausea, vomiting, abdominal pain, diarrhea, constipation, bloody stool, change in bowel frequency, dyspepsia, melena
    • GU: Denies dysuria, discharge, change in frequency, hematuria, itching, burning
    • Endo: Denies polydipsia, polyuria, polyphagia, heat or cold intolerance
    • MSK: Denies back pain, neck pain, joint pain, muscle pain, decreased range of motion, excessive weakness, swelling, redness
    • Integumentary: Denies dryness, itching, flaking, hair loss, rashes, lesions, nail changes
    • Neuro: Denies numbness, tingling, weakness, LOC, gait disturbance, seizure
    • Heme: Denies history of excessive bleeding, bruising, anemia, or transfusions
    • Psych: Denies anxiety, problems sleeping, depression, SI
  4. 8 System Physical Exam (PE)
    • Constitutional: Alert, well nourished, no acute distress
    • Eye: Normal conjunctiva, without scleral icterus, PERRLA, EOMI
    • HENT: Atraumatic, hearing grossly intact, without nasal discharge, moist oral mucosa, grossly average neck circumference, without JVD, without sinus tenderness, clear tympanic membranes, neck nontender to palpation, without carotid bruits, without masses, without lymphadenopathy
    • Resp: Clear to auscultation bilaterally, non-labored respiration on room air, without rales/rhonchi, without wheezing
    • CV: Normal rate, regular rhythm, without murmurs on auscultation, gallops, or rubs
    • GI: Soft, non-tender, non-distended, without obvious masses, bowel sounds present, w/o rigidity or guarding
    • GU: No tenderness, no discharge, no lesions
    • MSK: Extremities non-tender to palpation, without LE edema bilaterally, without obvious deficits in range of motion or strength, able to ambulate w/o assistance
    • Skin: Skin is warm, dry, and pale, without rashes or lesions
    • Heme/Lymph/Imm: Without obvious bleeding, without significant bruising, no lymphadenopathy
    • Psychiatric: Cooperative, appropriate mood and affect, normal judgement
    • Neurologic: Awake and oriented X4, No focal neuro deficits, CN II-XII intact
  5. Assessment/Plan
    1. Problems from your problem list auto-populate into your contextual view
      • See the examples linked below of how to generate your assessments/plans
        • PAST/PRESENT/FUTURE GAME
    2. Preventive Measure
      • Code Status: DNR/DNI, Full Code, DNR/Ok to intubate, DNI/CPR ok
      • Lines:
      • VTE PPX:
      • Diet:
      • Disposition:
  6. Signature
  7. Sign Note to Attending