Components
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 can include the following sections:
| Section | Example | Comments |
|---|---|---|
| chief complaint (CC) | "abdominal pain" | 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 symptom from a patient. |
| history of present illness (HPI) | "Pt is a 30 yo female (with a PMH of x and y) presenting with a 3 hour history of abdominal pain..." | Including a separate paragraph summarizing related history. May follow OPQRST 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. |
| review of systems (ROS) | "negative except as above" | Brief or handwritten ROS sections are often very brief, while template-driven ROS sections from electronic medical records often explicitly enumerate each system reviewed. |
| allergies | "NKDA" | 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) |
| medications | "none" | Includes both prescription and over-the-counter medications. May also include herbal medications or nutritional supplements. May include data on dosage and compliance. |
| past medical history (PMH) | "none" | Although remote childhood PMH is sometimes omitted, this information can sometimes be useful (for example, childhood asthma can be associated with adult atopic disorders.) |
| past surgical history (PSH) | "none" | Admissions to a hospital not associated with a surgery are also sometimes included here, though admissions associated with childbirth are often described in a distinct section. For example, a "OB/GYN" section may be included, including language such as "G3P2, menarche at age 14, LMP 2 weeks ago, regular". |
| family history (FH) | "noncontributory" | Including health of siblings, parents, spouse, and children, living and dead. Age of diagnosis may also be included (for example, in conditions such as colon cancer). 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. |
| social history (SH) | "Denies x3" | Can be very detailed. Usually includes information about tobacco use, alcohol, and illegal or recreational drugs. Each of these may include quantities or frequencies, and responses to CAGE questions may be reported. May also include information about travel and occupation. May also include sexual history, though this may be split off in a separate section. |
| physical exam | see Physical examination#Example | see Physical examination#Example |
| labs and diagnostics studies | "none" | May cover studies performed at an outside hospital, during prior admissions, or in the ER before the current admission. |
| assessment and plan (A&P) | "Pt is a 30 yo female..." | 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 actions associated with each item on the problem list. Additional sections for "fluids, electrolytes, and nutrition" and "disposition" may be added near the end. |
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