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:
chief complaint
history of present illness, including a separate paragraph summarizing related history
review of symptoms
allergies, including drug allergies (including antigens and responses)
past medical history
past surgical history
family history, including health of siblings, parents, spouse, and children, living and dead
social history
medications
physical exam
labs
diagnostics studies
assessment
plan
Outline
Not every admission note explicitly discusses every item listed below, however, the ideal admission note would include:
Header
Patient identifying information (maybe located separately)
name
ID number
chart number
room number
date of birth
attending physician
sex
admission date
Date
Time
Service
Chief complaint (CC), typically one sentence including
age
race
sex
presenting complaint
example: "34 yo white male with right-sided weakness and slurred speech."
History of present illness (HPI)
statement of health status
detailed description of chief complaint
positive and negative symptoms related to the chief complaint based on the differential diagnosis the health care provider has developed.
emergency actions taken and patient responses if relevant
