How to write an effective admissions note

The admission note for a patient is really important. For the nurses it signifies that the medical team treating the patient is aware of them and their current level of stability and that there is a plan in place for their admission. For the doctors involved in treatment it is one of the most read entries in the notes because it provides a summary of why the patient is in hospital, and their background. This is crucially important for an after-hours doctor reviewing a patient they may not be familiar with or if another medical team is consulting on the patient. When it comes time to write the discharge summary the admission note is also really useful.

1. Housekeeping, this is the same as for progress notes, see this post here.

2. Format, most formats used in admission note follow a similar structure. A typical outline might be as follows:
- Presenting complaint (often abbreiviated PC or CC (chief complaint))
- Past medical history or Background (PMHx)
- Medications (Meds)
- Allergies
- History of presenting complaint (HoPC)
- Review of Systems (RoS)
- Social history (SHx)
- If relevant family (FHx), occupational, and travel history
- The Physical examination (O/E stands for on examination)
- Laboratory and imaging studies (Ix)
- An impression (Imp) and/or a differential diagnosis (DDx) and/or a problem list (Issues)
- The plan (sometimes simply ‘P’ with a circle around it)

The order of these will depend on the person writing the notes. In many textbooks the HoPC comes before the PMHx, Meds and Allergies however it makes more sense to include those three things first unless the patient does not have any medical records. This is because (1) they are kind of details you want to be able to find quickly by flicking to the front of the notes, (2) it’s usually easier to be clear on these details before you take the HoPC as the patient may not be certain about them and your notes end up messy and less user-friendly if you have to go back and add things. The order, however, is of relative unimportance so long as the information is there.

The presenting complaint is a one or two line summary that aims to concisely identify the crux of the patient’s presentation. The diagnosis may be clear by the time you see the patient (e.g. ED have already worked them up or they’ve been sent in by their GP or specialist) or it may not be. If it is you include the diagnosis if not you include the presenting complaint. For example:
- A 66 year old man presents with non-critical aortic stenosis with a background of obesity, T2DM (type 2 diabetes mellitus), and HTN (hypertension)
- A 66 year old man presents with a ²/₅₂ (two week) history of exertional angina and a systolic murmur
It is sometimes best to leave the a space for the PC and fill it in after you’ve finished seeing the patient.

The past medical history may be separated into past surgical/psychiatric/obstetric etc history. It should include a list of the patients diagnoses and ideally the year they were diagnosed, the doctor who manages it, and sometimes some indication of their stage of treatment. For example:
- T2DM 1998, known to Dr. Jones (Endocrinologist), on 32 units of insulin (T2DM can be treated with diet alone, medications or insulin in that order according to severity)
Usually this information can be gleaned from the medical record, alternatively you might consider calling the patient’s GP or their specialist’s reception and asking them to fax over relevant correspondence. You’ll be thankful to an intern who writes a good discharge summary for finding this information quickly. Be aware that old medical records may not be consistent with the patient’s current medical history

Medications and Allergies are also usefully gleaned from the old medical record but it is very important to confirm these with the patient because (1) medications change frequently or they may not be adherent to their medications, (2) allergies are things that need to be checked 2, 3, 4 or more times over.

The history of presenting complaint is a more comprehensive exploration of the PC. Typically it is organised according to a symptom. For example, medical students are commonly taught how to take a ‘pain history’ and the details of this would go here. This requires a lot of skill and knowledge, however, because there are many different presentations. For example a patient presenting with shortness of breath in the context of asthma might be asked the standard shortness of breath questions as well as an ‘asthma history’ e.g. have you been in hospital for your asthma, have you ever been in ICU, do you take steroids orally, what are your triggers, how often do you need to use your relievers, as well as questions to assess if there is any underlying psychiatric conditions (which are unusually common among asthmatics).

The Review of Systems is a umbrella, catch-all, series of questions designed to minimise the chances of anything serious being missed. It includes for example, regarding the cardiovascular system: chest pain, palpitations, paroxysmal nocturnal dyspnoea, ankle swelling etc. For the urinary system: polyuria, nocturia, dysuria, frequency, incontinence, flank pain etc. It is upper to the person taking the history as to how extensive the RoS is but should minimally include a brief overview of the cardiac, respiratory, abdominal, urinary, and neurological systems.

The social history is a common pit-fall in the admission note for being too brief. Often it will simply include the patient’s smoking status (which should be recorded in pack years as well as making it clear whether the patient is a smoker/non-smoker/ex-smoker) and alcohol consumption (which should be recorded in standard drinks per day or week – it’s ok to estimate this).

A SHx should include more than just that though. Typically it should also include where the patient lives (e.g. own home, low-level self-contained aged care, nursing home) and whether it has been modified for their disabilities and/or if there are stairs to climb; their level of independence (e.g. do they need a walking aid, can they attend to their own hygiene, finances, etc) and how they get around (can they drive). It is also worth assessing how much support they have from family/friends.

Other things that may be important include pets, nutrition, sleep quality/hygiene, their most pressing problems (e.g. they may be a carer for their wife/husband), and their hobbies/interests.

A family history is important for (often rare) inherited conditions, most cancer patients, and all patients presenting with chest pain (a first degree relative in their 50s if male or 60s if female – or younger – is a significant risk factor for ischaemic heart disease). Occupational history may be important for, as an example, heavy-lifting requirements after abdominal surgery. Travel history is relevant for exposure to infections like tuberculosis or malaria, and risk of developing clots in the leg through not moving around on an aeroplane for long periods of time.

Many textbooks have been written on the examination so I won’t go into it in detail except to offer a mnemonic for its structure, the commonly used ABCDEFG.
- Appearance: e.g. obese, well, unwell, in pain,
- BMI: an estimate along the lines of not overweight, overweight, obese or morbidly obese is ok
- Cognition: often simply whether they are alert and interactive, if this appears not to be the case whether they are orientated to time, place and person and if necessary further questions up to and/or including a mini-mental status examination
- Devices and attachments: this is things like IV cannulas (IV lines), indwelling urinary catheters, drainage bags, stoma bags, prostheses, nasal prong oxygen, etc.
- Entire body: usefully divided into HEENT (head, ear, eye, nose throat), Cardio, Resp, Abdominal, Neuro, and Muskuloskeletal
- Functionality: tests of function may be relevant especially the timed ‘get-up-and-go test’
- Gait: may be relevant e.g. normal/safe, antalgic, scissor (e.g. cerebral palsy), ataxic (e.g. drunk, cerebellar), shuffling (Parkinson’s), high-stepping (foot drop), circumduction (stroke), wide-based, trendelenberg (hip pain).

Laboratory investigations and imaging will usually include things like Na⁺/K⁺/Urea/Creatinine, Haemoglobin (Hb)/White Cell Count WCC/Platelets (Plts), Ca⁺⁺/Mg⁺⁺/PO₄^-, and perhaps albumin/bilirubin/GGT/ALP/ALT/AST for laboratory investigations. Other investigations will depend on the patient (e.g. troponins in a patient with chest pain)

12 lead Electrocardiograms (ECG) are often relevant here (again, in chest pain, something like no acute changes or no ST deviation or T wave changes).

Chest X-rays (CXR) and Abdominal X-rays (AXR) with a brief summary of the key findings.

The impression will usefully include what you think is going on e.g. chest pain, cannot exclude a cardiac cause. Or Acute pulmonary oedema secondary to AF secondary to ? with a DDx such as ischaemic heart disease, cardiomyopathy, thyrotoxicosis, ethanol, idiopathic etc. The problem (or issue) list will include similar things described to in the progress note post above.

The plan includes things the medical team intends to do for the patient and orders for the nursing and other staff. It is usefully divided up into plans for further investigation e.g. repeat ECG, check thyroid function tests, telemetry bed on the ward, chase correspondence from GP; plans for treatment e.g. increase metoprolol to 100mg BD, restrict fluid intake to 1.2L; and plans for patient logistics e.g. admit under Dr. Jones, transfer to rehabilitation, or discharge home.