22:
456:
Assessment and plan are very closely related, and are often reported in a single section. May be begun with a paragraph that is similar to the first line of the HPI, but with a greater emphasis on clinical reasoning. A list of problems may be organized by priority or by organ system, with specific
279:
including drug allergies (including antigens and responses). "NKA" = "no known allergies". "NKDA" = "no known drug allergies". Some sources include both acronyms, which reduces ambiguity between drug allergies and other allergies (such as food allergies or allergies to pets)
221:
Can also include a more detailed line, such as "30 yo F c/o abdominal pain", though this can be redundant to the HPI. Some notes include a "reason for consultation", which is similar but may address a physical finding from a physician as opposed to a
127:
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
653:
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.
180:, 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.
248:
or similar format. Components from review of systems may be moved here if they are seen as relevant to the chief complaint. May exclude first line if this information is included in CC section.
917:
176:
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
599:
List of the patient's on-going medical problems. Chronic problems should be addressed as to whether or not they are well controlled or uncontrolled. Include dates of pertinent items.
1009:
173:
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Includes both prescription and over-the-counter medications. May also include herbal medications or nutritional supplements. May include data on dosage and compliance.
457:
actions associated with each item on the problem list. Additional sections for "fluids, electrolytes, and nutrition" and "disposition" may be added near the end.
767:
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1607:
141:
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Including health of siblings, parents, spouse, and children, living and dead. Age of diagnosis may also be included (for example, in conditions such as
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32:
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363:). A phrase such as "no family h/o of heart or lung problems" may be used to specifically indicate that questions about a system were asked.
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positive and negative symptoms related to the chief complaint based on the differential diagnosis the health care provider has developed.
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Admissions to a hospital not associated with a surgery are also sometimes included here, though admissions associated with
1818:
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are often described in a distinct section. For example, an "OB/GYN" section may be included, including language such as "
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Not every admission note explicitly discusses every item listed below, however, the ideal admission note would include:
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May cover studies performed at an outside hospital, during prior admissions, or in the ER before the current admission.
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Although remote childhood PMH is sometimes omitted, this information can sometimes be useful (for example, childhood
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Assessment includes a discussion of the differential diagnosis and supporting history and exam findings.
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Brief or handwritten ROS sections are often very brief, while template-driven ROS sections from
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192:) or H and P (history and physical), which include only portions of an admission note.
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example: "34 yo white male with right-sided weakness and slurred speech."
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Including a separate paragraph summarizing related history. May follow
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An admission note may sometimes be incorrectly referred to as an HPI (
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questions may be reported. May also include information about
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List of surgeries in the past with dates of pertinent items.
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Patient identifying information (maybe located separately)
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emergency actions taken and patient responses if relevant
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Can be very detailed. Usually includes information about
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An admission note can include the following sections:
951:. Lippincott Williams & Wilkins. pp. 300–.
1608:
Health
Insurance Portability and Accountability Act
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266:often explicitly enumerate each system reviewed.
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1666:Participative decision-making in organizations
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168:. These notes constitute a large part of the
29:The examples and perspective in this article
119:Admission notes document the reasons why a
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67:Learn how and when to remove this message
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562:detailed description of chief complaint
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172:. Medical students often develop their
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669:for each: generic name - amount - rate
603:Past surgical history (PSurgHx, PSxHx)
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1397:Upper limb neurological examination
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1686:Health information on the Internet
14:
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527:Typically one sentence including
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548:History of present illness (HPI)
20:
1819:Open-source healthcare software
1694:Health information on Knowledge
1418:Ballard Maturational Assessment
1278:Peripheral vascular examination
916:Hoholik, Suzanne (2011-02-14),
1044:History of the present illness
945:Ellen Chiocca (1 March 2010).
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621:Health or cause of death for:
554:History of the present illness
385:, and illegal or recreational
1:
1385:Mini–mental state examination
1296:Ankle–brachial pressure index
948:Advanced Pediatric Assessment
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311:can be associated with adult
183:
178:U.S. medical billing industry
101:physical examination findings
676:, Goody's medicated powder,
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423:Physical examination#Example
417:Physical examination#Example
7:
1636:Doctor–patient relationship
1543:Telemedicine and telehealth
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804:investigates the body of a
595:Past medical history (PMHx)
587:second antigen and response
259:"negative except as above"
43:, discuss the issue on the
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1671:Patient Activation Measure
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800:is the process by which a
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453:"Pt is a 30 yo female..."
264:electronic medical records
232:history of present illness
190:history of present illness
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617:Family history (medicine)
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174:clinical reasoning skills
1699:Online patient education
1603:Electronic health record
672:medications on arrival (
1464:Athletic heart syndrome
819:
735:Gastrointestinal system
718:Throat, mouth, and neck
692:Review of systems (ROS)
687:medications on transfer
345:2 weeks ago, regular".
1824:Patient opinion leader
1676:Shared decision-making
1613:Personal health record
1501:Differential diagnosis
1436:Well-woman examination
755:Musculoskeletal system
639:Social history (SocHx)
123:is being admitted for
107:is being admitted for
1656:Knowledge translation
1623:Patient participation
725:Cardiovascular system
611:Family history (FmHx)
321:past surgical history
1829:Research participant
1469:Sudden cardiac death
1352:Shoulder examination
1291:Abdominojugular test
1124:Physical examination
1071:Past medical history
983:Admitting privileges
834:liver function tests
830:arterial blood gases
802:health care provider
798:clinical examination
794:Physical examination
787:Physical examination
540:presenting complaint
517:Chief complaint (CC)
299:past medical history
49:create a new article
41:improve this article
31:may not represent a
1855:Medical terminology
1550:Background concepts
1488:Assessment and plan
1273:Cardiac examination
1218:Swinging light test
1086:Psychiatric history
1019:Medical examination
869:Assessment and plan
863:Assessment and plan
664:Pharmaceutical drug
495:attending physician
448:assessment and plan
401:. May also include
150:postoperative notes
103:), reasons why the
87:that documents the
1803:Telerehabilitation
1557:Health informatics
1446:Breast examination
1321:Rectal examination
1255:Respiratory sounds
1054:Nursing assessment
922:Columbus Dispatch
768:Hematologic system
730:Respiratory system
356:"noncontributory"
142:preoperative notes
1842:
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1778:Teleophthalmology
1768:Telemental health
1753:Tele-epidemiology
1598:De-identification
1570:Telecommunication
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1496:Medical diagnosis
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1357:Elbow examination
958:978-0-7817-9165-6
698:Review of systems
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254:review of systems
218:"abdominal pain"
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51:, as appropriate.
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893:. Archived from
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773:Endocrine system
715:Nose and sinuses
226:from a patient.
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130:on-service notes
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928:on 2013-01-22
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779:Physical exam
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83:is part of a
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27:
18:
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1788:Telepharmacy
1587:
1562:
1372:Neurological
1326:Bowel sounds
1283:Heart sounds
1147:Auscultation
962:. Retrieved
947:
940:
930:, retrieved
926:the original
921:
911:
899:. Retrieved
895:the original
885:
872:
843:
826:electrolytes
823:
797:
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792:
652:
620:
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526:
486:chart number
467:
374:"Denies x3"
361:colon cancer
315:disorders.)
194:
187:
118:
80:
78:
63:
54:
30:
1773:Telenursing
1593:Blue Button
1565:health care
1563:In absentia
1413:Apgar score
1362:GALS screen
1247:Respiratory
1175:Temperature
1167:Vital signs
1064:Medications
840:Diagnostics
764:Psychiatric
658:Medications
489:room number
434:diagnostics
341:at age 14,
286:medications
95:(including
1646:Health 2.0
1316:Liver span
1180:Heart rate
1157:Percussion
1142:Inspection
1095:Mnemonics
932:2011-06-03
877:References
450:(A&P)
399:occupation
331:childbirth
184:Components
138:SOAP notes
1641:E-patient
1308:Abdominal
1152:Palpation
1059:Allergies
573:Allergies
483:ID number
272:allergies
207:Comments
45:talk page
1849:Category
1441:Pap test
1406:Neonatal
1132:General/
1113:COASTMAP
977:See also
631:Children
628:Siblings
436:studies
339:menarche
204:Example
201:Section
39:You may
1728:eHealth
1661:mHealth
1225:Hearing
964:20 June
901:3 April
836:, etc.
814:disease
806:patient
721:Breasts
703:General
684:, etc.)
674:aspirin
625:Parents
579:Allergy
512:Service
464:Outline
439:"none"
383:alcohol
379:tobacco
326:"none"
304:"none"
290:"none"
276:"NKDA"
224:symptom
121:patient
115:Purpose
105:patient
97:history
89:patient
1704:PubMed
1456:Sports
1287:Other
1104:OPQRST
1099:SAMPLE
955:
844:e.g.:
824:e.g.:
634:Spouse
472:Header
395:travel
323:(PSH)
313:atopic
309:asthma
301:(PMH)
256:(ROS)
246:OPQRST
234:(HPI)
164:, and
93:status
1474:RED-S
1235:Rinne
1230:Weber
1200:HEENT
810:signs
387:drugs
381:use,
371:(SH)
353:(FH)
241:..."
215:(CC)
47:, or
1134:IPPA
1109:SOAP
1021:and
966:2011
953:ISBN
903:2009
820:Labs
808:for
712:Ears
709:Eyes
706:Head
590:etc.
534:race
509:Time
506:Date
480:name
432:and
430:labs
421:see
415:see
397:and
391:CAGE
335:G3P2
99:and
858:MRI
850:CXR
846:EKG
812:of
796:or
537:sex
531:age
498:sex
343:LMP
140:),
91:'s
79:An
1851::
920:,
856:,
854:CT
852:,
848:,
832:,
828:,
816:.
680:,
337:,
160:,
156:,
152:,
148:,
144:,
132:,
1535:e
1528:t
1521:v
1011:e
1004:t
997:v
968:.
905:.
136:(
70:)
64:(
59:)
55:(
37:.
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