The sample notes provide most of the questions to ask while collecting patient history, the common physical findings, and the typical assessment and plan.

Having the basics pre-written in front of you may help you discover some unusual and challenging findings in atypical clinical situations.

If you want to print a note, just select the text with the mouse, and choose print selection from the print menu.

Cardiology Admission Note for Shortness of Breath (SOB), CHF Admission Note for Chest Pain Admission Note for Syncope Admission Note for Chest Pain, ICU Pulmonology and Critical Care Admission Note for SOB, Asthma Admission Note for SOB, Pneumonia Admission Note for Ventilated Patient, ICU Admission Note for Alcohol or Drug Overdose Gastroenterology (GI) Admission Note for NVD Admission Note for GI Bleed Admission Note for Abdominal Pain Nephrology Admission Note for ESRD, HD, AVF Endocrinology Admission Note for DKA, ICU HematologyOncology Admission Note for Sickle Cell Crisis Rheumatology Admission Note for Back Pain Infectious Diseases (ID) Admission Note for Leg Pain Admission Note for Infection Admission Note for Septic Shock, ICU Admission Note for Pelvic Pain, PID, GU Sx Neurology Admission Note for Dizziness Admission Note for Seizures Admission Note for Change in MS References AudioVideo SOAP Note 101 Series.

Hospital Admission Template Series Designed For

The Texas Tech Medcast: A podcast series designed for first-year medical students who are learning how to write an effective patient note for a medical record.

Further Reading Admission Note - Universal Note Progress Note - SOAP Format Procedure Note Happys Hospitalist Order Sets, 082008.

EMR (Epic) primer: Our Most Expensive Typing Pool.

Dr. Wes, 092008. Collecting History: Pulling Teeth.

The information provided here is for educational purposes only and is not intended to provide medical advice.

By accessing the web site, the visitors acknowledge that there is no physician-patient relationship between them and the authors.

Hospital Admission Template Upgrade And Update

Update In April of this year, we revisited our standard orders to upgrade and update them.

See FPM CME Quiz.

In 1999, the 17 family physicians of the Scott White Clinic in College Station, Texas, developed a set of standardized orders for use in admitting patients to the hospital.

One year prior to this, we had started a hospital service consisting of one of our senior staff physicians working with a second-year resident from the local family medicine residency.

Eventually, all of our physicians began to share this responsibility one week at a time, which left each of our doctors having a fairly intensive inpatient experience every three to four months.

Because of the wide scope of family medicine, we cared for patients with a wide variety of medical conditions.

Many of these patients problems were relatively routine, while others were less common or more complex and, therefore, more difficult for our admitting physicians to manage.

Our reasons for developing the standardized admission orders were threefold.

First, we felt we could reduce unnecessary variability in physicians approaches to similar disease processes and thereby improve the quality of our care.

Like many physicians, we were sometimes basing our care on what we learned in training or from colleagues, rather than on current evidence.

Second, we felt that by reducing variability, the orders could also help contain costs.

As we created the admission orders, we reviewed them with local specialists in the relevant fields and also with our primary hospital to help establish the most cost-effective therapies for our particular hospital practice.

For example, in the treatment of UGI bleeding, many of our physicians were using IV H 2 -blockers for initial management, although oral medications were as effective yet less costly in patients not actively vomiting.

Our third reason for developing the orders was simply a matter of physician convenience and efficiency.

At 2 a.m., locating the correct dose of acetylcysteine for an acetaminophen overdose using our standardized orders is much easier than trying to locate it in a textbook.

The process Once we decided which conditions we wanted to develop standard orders for, we assigned just one or two to each of our physicians to research and compose.

We encouraged the physicians to take an evidence-based approach, and we sought input from appropriate specialists.

The orders were then formatted using a standard template to ensure that routine issues such as diet, activity, prn medications, etc., were covered.

The hospital information system staff then assisted us in making the forms easily accessible from any of the computer workstations throughout the hospital.

We can also access the forms at our clinic and at our urgent care department, where many of our admissions originate.

Experience Our experience using the standard admission orders over the past two years has been very positive.

We believe the orders have in fact helped us with cost, quality and convenience.

It is important to realize that these orders are intended only as a framework to aid the doctors and residents as they begin the work-up and treatment of patients.

We do not require the physicians or residents to use the standard orders but have found that most choose to do so.

We request that the residents write their own orders for their education purpose, but we ask that they use our standard orders in the hospital for quality-control purposes.

We also understand that not every patient should be treated exactly the same, and we encourage our physicians to provide individualized patient care as they deem appropriate.