admission notes examples

3 min read 25-02-2025

Meta Description: Need help writing admission notes? This guide provides various examples of admission notes for different situations, covering everything from straightforward admissions to more complex cases. Learn how to write clear, concise, and legally sound admission notes for optimal patient care. (158 characters)

Understanding the Importance of Admission Notes

Admission notes are the cornerstone of a patient's medical record. They provide a concise yet comprehensive summary of the patient's presenting complaint, medical history, current status, and the planned treatment strategy. Accurate and detailed admission notes are crucial for ensuring continuity of care, facilitating effective communication among healthcare professionals, and minimizing the risk of medical errors. They are also legally important, serving as a record of the care provided.

Types of Admission Notes & Examples

The format of an admission note can vary slightly depending on the healthcare setting and the patient's condition. However, certain key elements should always be included. Below are examples illustrating different scenarios:

1. Straightforward Admission Note Example:

Patient: John Doe, 65-year-old male

Date of Admission: October 26, 2024

Reason for Admission: Acute exacerbation of chronic obstructive pulmonary disease (COPD)

Presenting Complaint: Increased shortness of breath, productive cough with yellow sputum, and increased fatigue over the past 3 days.

Past Medical History: COPD, hypertension, hyperlipidemia.

Allergies: NKDA (No Known Drug Allergies)

Current Medications: Albuterol inhaler, ipratropium inhaler, lisinopril, atorvastatin.

Physical Exam: Tachypneic, using accessory muscles to breathe. Crackles heard bilaterally in lung bases. Heart rate 100 bpm, regular rhythm. Blood pressure 140/90 mmHg.

Assessment: Acute exacerbation of COPD.

Plan: Oxygen therapy, bronchodilator nebulizers, intravenous corticosteroids, blood gas analysis, chest x-ray. Consider antibiotics if cultures are positive.

2. Admission Note with Complex Medical History:

Patient: Jane Smith, 42-year-old female

Date of Admission: November 5, 2024

Reason for Admission: Severe abdominal pain and vomiting.

Presenting Complaint: Sudden onset of severe abdominal pain localized to the right lower quadrant, associated with nausea and vomiting for the past 6 hours.

Past Medical History: History of endometriosis, two previous laparoscopic surgeries.

Allergies: Penicillin (allergic reaction)

Current Medications: Oral contraceptives.

Physical Exam: Tachycardia, guarding and rebound tenderness in the right lower quadrant. Positive Rovsing’s sign.

Assessment: Suspected appendicitis.

Plan: Complete blood count (CBC), inflammatory markers (CRP, ESR), abdominal CT scan. Surgical consultation obtained. NPO (nothing by mouth) status. IV fluids. Pain management with analgesics.

3. Admission Note for a Psychiatric Patient:

Patient: Michael Brown, 30-year-old male

Date of Admission: December 12, 2024

Reason for Admission: Suicidal ideation.

Presenting Complaint: Expressing feelings of hopelessness, worthlessness, and having thoughts of self-harm.

Past Medical History: Major depressive disorder, anxiety disorder. History of previous suicide attempts.

Allergies: NKDA

Current Medications: Sertraline, lorazepam as needed.

Mental Status Exam: Depressed mood, tearful, anxious. Speech slowed. Thought process linear but preoccupied with suicidal ideation. Insight and judgment impaired.

Assessment: Major depressive episode with suicidal ideation.

Plan: One-to-one observation, suicide precautions, initiation of antipsychotic medication, psychiatric consultation.

Key Elements of a Well-Written Admission Note:

Clear and Concise Language: Avoid medical jargon. Use simple, straightforward language.
Chronological Order: Present information in a logical sequence.
Objective Data: Focus on factual observations, not subjective interpretations.
Complete Information: Include all relevant details, such as vital signs, allergies, and current medications.
Legibility: Ensure the note is easy to read and understand.
Accuracy: Double-check all information for accuracy before submitting the note.
Signature and Date: Always sign and date your admission note.

Legal Considerations for Admission Notes:

Admission notes are legal documents. Therefore, it is crucial to ensure that they are accurate, complete, and objective. Avoid making subjective judgments or opinions. Always document factual information. If a mistake is made, correct it appropriately and document the correction. Consult with legal counsel if you have any questions about legal requirements.

Conclusion

Writing effective admission notes is a crucial skill for any healthcare professional. By following these examples and guidelines, you can ensure that your notes are clear, concise, complete, and legally sound, contributing to optimal patient care and effective communication within the healthcare team. Remember, accurate documentation is paramount for both clinical practice and legal protection.