Admission note
An admission note is a foundational document in a patient's medical record, prepared by a physician or qualified healthcare provider upon hospital admission to summarize the circumstances of the patient's presentation, including the chief complaint, history of the present illness, pertinent past medical history, review of systems, physical examination findings, laboratory and diagnostic results, working diagnosis, and initial treatment plan.[1][2] This note, often structured as a history and physical (H&P) examination report, establishes the baseline clinical status and rationale for inpatient care, facilitating communication among the healthcare team and serving as a medico-legal record of the admission decision.[3][4] The primary purpose of the admission note is to justify the necessity of hospitalization by linking the patient's symptoms and findings to required diagnostic or therapeutic interventions, while enabling ongoing assessment of progress and potential complications during the stay.[2][5] Key components typically include patient demographics (such as age, sex, and allergies), a detailed narrative of the events leading to admission, social and family history where relevant, and risk assessments like fall potential or skin integrity.[6][7] Accurate and timely completion of this note is critical for regulatory compliance, insurance reimbursement, and defense against potential litigation, as incomplete documentation can undermine care coordination or lead to adverse outcomes.[4][8] Variations exist between medical and nursing admission notes, with the latter emphasizing psychosocial needs, learning requirements, and immediate care priorities to support bedside management.[4][9] Standards for formatting draw from established frameworks like the SOAP (Subjective, Objective, Assessment, Plan) method, though admission notes prioritize comprehensiveness over brevity to capture the full clinical context at entry.[8][9] In practice, electronic health record systems have standardized templates to reduce errors and ensure consistency, reflecting empirical evidence that structured documentation improves patient safety and interdisciplinary handover.[6][10]Definition and Purpose
Definition
An admission note is the initial comprehensive documentation in a patient's medical record upon hospitalization, typically prepared by the admitting physician or advanced practice provider, that captures the patient's presenting condition, relevant history, physical examination findings, initial assessment, and preliminary care plan. This note establishes the baseline clinical status and rationale for inpatient admission, serving as a primary reference for the healthcare team throughout the hospital stay.[11][12] Often structured as a history and physical (H&P) examination report, the admission note adheres to standardized formats such as the SOAP (Subjective, Objective, Assessment, Plan) or more detailed narrative styles, ensuring key elements like chief complaint, history of present illness, past medical history, review of systems, vital signs, and laboratory results are systematically recorded to facilitate continuity of care and medicolegal accountability.[13][14] Variations may exist for nursing admission notes, which focus more on immediate patient needs and baseline assessments upon unit arrival, but the physician-led admission note remains the cornerstone for diagnostic and therapeutic decision-making.[4]Primary Functions
The admission note primarily serves to document the patient's initial clinical status upon hospitalization, capturing the chief complaint, relevant history, physical examination findings, and preliminary diagnostic impressions to establish the medical necessity for inpatient care. This documentation links observed symptoms and test results to the rationale for admission, such as the need for acute monitoring, therapeutic interventions, or further evaluation not feasible in outpatient settings.[2][15] A core function is to enable effective interdisciplinary communication by providing a structured baseline for subsequent caregivers, including nurses, consultants, and specialists, thereby promoting continuity of care and reducing errors in treatment execution. For instance, it records vital signs, allergies, current medications, and social factors that inform immediate management decisions.[3][16] Additionally, the note functions as a legal and regulatory record, supporting physician certification of the admission, compliance with standards like those from the Centers for Medicare & Medicaid Services, and potential medico-legal review in cases of adverse outcomes. It also underpins billing processes by justifying resource utilization and serves as a data source for quality assurance, research, and institutional audits.[15][17]Clinical and Legal Significance
Admission notes serve as a foundational clinical tool by providing a detailed baseline assessment of the patient's condition at the time of hospital entry, which guides diagnostic evaluations, treatment planning, and ongoing management decisions.[18] This documentation captures essential elements such as history, physical examination findings, and initial laboratory results, enabling healthcare providers to track progress, adjust interventions, and avoid redundant testing, thereby optimizing patient outcomes.[19] In multidisciplinary settings, these notes facilitate effective communication among physicians, nurses, and other professionals, ensuring continuity of care across shifts and reducing errors in high-volume hospital environments.[20] From a treatment perspective, admission notes document prediagnostic assessments and medication histories, which form the basis for inpatient regimens and help mitigate risks such as adverse drug interactions during hospitalization.[20] Studies emphasize that comprehensive notes written close to the time of admission correlate with improved clinical reasoning documentation and better alignment of care plans with patient needs.[18] Legally, admission notes function as primary medico-legal records, offering contemporaneous evidence of the clinician's rationale, actions, and patient interactions, which can be pivotal in litigation occurring years after the event.[18] Thorough documentation protects both providers and patients by demonstrating adherence to standards of care, supporting defenses against malpractice claims—particularly in high-risk scenarios involving delayed diagnoses or treatment refusals—and ensuring accountability through requirements for accuracy, legibility, and internal consistency.[21][19] Failure to maintain such records heightens vulnerability to legal challenges, as courts often rely on them to verify informed consent, service delivery, and deviations from accepted practice.[21]Historical Development
Early Origins
The practice of documenting patient admissions traces its roots to ancient civilizations, where rudimentary records of illnesses and treatments served educational and archival purposes. In ancient Egypt, medical papyruses such as the Edwin Smith Papyrus, dating to approximately 1600–1700 BC, detailed examinations, diagnoses, and interventions for injuries, marking early structured clinical narratives akin to initial assessments.[22] Similarly, Sumerian cuneiform tablets from around 3000 BC recorded health events, though these were episodic rather than systematic admission logs.[22] Hippocratic case histories from the 5th–4th centuries BC in Greece further advanced this by compiling observational notes on symptoms, prognoses, and outcomes, influencing later European traditions without formal hospital contexts.[23] Medieval European hospitals, often managed by religious orders, maintained basic admission and discharge lists as the first institutionalized archiving of patient entries, primarily for administrative accountability rather than clinical detail.[22] These lists, preserved in monastic records, captured entry dates, patient demographics, and release statuses but lacked comprehensive histories or assessments, reflecting hospitals' roles more as charitable asylums than scientific institutions.[22] The Schola Medica Salernitana in 11th–12th century Italy contributed indirectly through compiled disease management texts, yet documentation remained fragmented until the Enlightenment era's emphasis on empirical observation. The emergence of proto-admission notes aligned with 18th-century teaching hospitals, where records evolved to support medical education and continuity of care. In 1724, Berlin's Charité Hospital instituted journals documenting patient conditions, treatments, and progress, enabling bedside teaching and case analysis.[22] Paris's Hôtel-Dieu Hospital followed in 1791 with its Journal de Chirurgie, which recorded surgical admissions, initial evaluations, and outcomes for research dissemination.[22] These developments prioritized narrative summaries of presenting complaints and baseline status upon entry, foreshadowing modern admission notes' focus on history and rationale for inpatient care, driven by the shift toward hospital-based scientific medicine.[22] In the early United States, New York Hospital adopted a Book of Admissions around 1793, systematically logging entry details alongside discharges to track patient flows and clinical data.[24]Mid-20th Century Standardization
The Joint Commission on Accreditation of Hospitals (JCAH), formed in 1951 as a successor to the American College of Surgeons' Hospital Standardization Program initiated in 1918, established minimum requirements for hospital record-keeping, mandating accurate, complete, and accessible patient records for all admissions to ensure quality care and facilitate review.[25][26] These standards emphasized the inclusion of detailed admission documentation, such as history, physical examination findings, and initial diagnostic plans, to support continuity of care and legal defensibility, reflecting post-World War II expansions in hospital infrastructure and the need for uniform practices amid rising patient volumes.[27] The 1950s and 1960s also saw formalization influenced by health insurance expansions, which required standardized clinical data for reimbursement and epidemiological tracking, shifting admission notes from ad hoc narratives to structured forms capturing essential elements like chief complaints and past histories.[28] Early computational tools, including punch-card systems in the 1950s, began aiding data processing for hospital records, laying groundwork for more systematic admission documentation, though paper-based formats predominated.[29] A pivotal advancement occurred in 1968 when Lawrence L. Weed, MD, published "Medical Records That Guide and Teach" in the New England Journal of Medicine, introducing the problem-oriented medical record (POMR) system. This framework standardized admission notes by requiring an initial comprehensive database—encompassing history of present illness, review of systems, and physical exam—followed by a numbered problem list and plans, replacing disorganized source-oriented entries with a logical, patient-centered structure to enhance clinical decision-making and interdisciplinary communication.[30] Weed's SOAP (Subjective, Objective, Assessment, Plan) format for subsequent notes built directly on this admission foundation, gaining widespread adoption in U.S. hospitals by the 1970s and influencing global standards.[31] The enactment of Medicare and Medicaid in 1965 further reinforced these standards, as accreditation by JCAH became prerequisite for federal funding, compelling hospitals to implement uniform admission protocols, including timely history and physical examinations within 24 hours of admission.[32] This era's emphasis on empirical completeness addressed prior variabilities in documentation quality, driven by causal needs for accountability in an increasingly litigious and regulated healthcare environment, though implementation varied due to resistance from physicians accustomed to narrative styles.[30]Modern Refinements
Following the standardization efforts of the mid-20th century, admission notes underwent substantial refinements driven by the digitization of health records, particularly through the adoption of electronic health records (EHRs). The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 provided financial incentives for hospitals to implement certified EHR systems, accelerating a shift from paper-based documentation to electronic formats that support real-time updates, interoperability across providers, and integration with laboratory and imaging data.[33] Prior to these incentives, only 9% of U.S. hospitals possessed basic EHR capabilities in 2008; adoption surged to 80.5% by 2015 and 96% by 2021, enabling admission notes to incorporate automated alerts for allergies, medication reconciliation, and clinical decision support tools that flag potential risks based on patient data.[34][35] This transition improved documentation completeness and reduced errors associated with illegible handwriting, though it introduced challenges like template-driven "note bloat" from excessive copy-paste practices.[36] EHR platforms further refined admission notes via standardized templates that enforce structured fields for components such as history of present illness and physical examination, minimizing omissions and promoting consistency across clinicians. A 2020 analysis of EHR implementation in hospitals demonstrated enhanced quality in admission documentation, with shorter dictation times for associated records due to pre-populated data from patient portals and prior encounters.[37] These templates often align with evidence-based guidelines, incorporating prompts for social determinants of health and patient-reported outcomes to support holistic assessments, while interoperability standards like those under the Promoting Interoperability program facilitate data sharing that informs initial admission plans.[38] Emerging refinements leverage artificial intelligence (AI) to automate note generation, addressing clinician burnout from documentation demands. Studies from 2024 evaluated large language models for producing accurate handoff and SOAP-structured admission notes from audio dictations or clinical inputs, achieving high fidelity to source material while reducing manual entry time by up to 50% in preliminary trials.[39][40] Concurrently, quality improvement efforts have targeted neutral language in EHR notes, with audits identifying and mitigating stigmatizing terms in admission summaries to prevent bias in care transitions, as evidenced by reviews of over 20,000 notes revealing such phrasing in 20-30% of cases before interventions.[41] Patient access to EHR portals has also refined accuracy, allowing self-corrections that enhance the reliability of histories incorporated into admission notes.[42] These advancements prioritize empirical efficiency and causal links between documentation precision and outcomes like reduced readmissions, though ongoing evaluation is needed to counter risks such as AI hallucinations in generated content.Standard Components
Header and Identifiers
The header and identifiers section of an admission note serves as the initial administrative framework, ensuring unique patient identification to mitigate errors in documentation, treatment, and billing. It typically includes the patient's full legal name, date of birth, and medical record number (MRN), which collectively function as core identifiers required by accreditation standards to verify patient identity before any clinical actions.[43] The MRN is a facility-specific alphanumeric code assigned upon first encounter, enabling linkage of all historical and current records across encounters.[44] Additional elements often encompass calculated age, sex assigned at birth, admission date and time, admitting physician's name, and inpatient unit or bed assignment, providing contextual details for immediate care coordination.[45] These components align with regulatory mandates for at least two distinct identifiers—such as name paired with MRN or date of birth—to prevent adverse events like medication mismatches or procedural mix-ups, as emphasized in national patient safety goals.[43] In electronic health record systems, the header may integrate dynamic alerts, such as critical allergies, displayed prominently for clinician reference.[45] Legally, this section supports auditability and compliance with health information privacy laws, including HIPAA in the United States, by documenting verifiable identity at admission onset.[46] Variations exist by jurisdiction and facility policy; for instance, UK standards under the Professional Record Standards Body recommend including identifier type, patient address, and contact details in admission records to enhance traceability.[47] Omissions or inaccuracies here can compromise downstream clinical decisions, underscoring the header's role in foundational record integrity.[44]Chief Complaint
The chief complaint in a hospital admission note is a concise statement, typically documented in the patient's own words, describing the primary symptom, problem, or condition that prompted the need for hospitalization.[48] This element serves as the foundational reason for the encounter, distinguishing it from secondary concerns and guiding subsequent documentation such as the history of present illness.[49] For instance, common examples include phrases like "shortness of breath for three days" or "severe abdominal pain since yesterday evening," which capture the urgency and immediacy of the presentation without interpretive embellishment by the clinician.[50] Eliciting the chief complaint occurs early in the admission process, often during triage or initial physician assessment, to ensure accuracy and patient-centered focus; alterations or paraphrasing by providers risk introducing bias or inaccuracy in the record.[11] In standardized formats like SOAP notes adapted for admissions, it precedes detailed histories and assessments, establishing medical necessity for inpatient care and supporting regulatory requirements for billing under systems such as Medicare, where its absence can lead to claim denials.[49] Documentation standards emphasize brevity—ideally one to two sentences—to maintain focus, while electronic health records often prompt structured entry to enforce inclusion.[48] Clinically, the chief complaint facilitates rapid prioritization of differential diagnoses and resource allocation in high-acuity settings, correlating with triage acuity scores and influencing admission decisions; studies indicate it predicts resource utilization more effectively than administrative codes alone.[51] Legally and for quality assurance, it provides a verifiable anchor for continuity of care, audit trails, and litigation defense, as incomplete or vague entries have been linked to adverse events in retrospective reviews.[52] Its fidelity to patient-reported data also aids in epidemiological tracking, such as chief complaint-based surveillance for outbreaks, underscoring its role beyond individual cases.[53]History of Present Illness
The History of Present Illness (HPI) constitutes the core narrative section of a hospital admission note, detailing the chronological progression of the patient's current symptoms from initial onset to the point of admission. It begins with a concise opening statement summarizing the patient's age, sex, and primary reason for seeking care, followed by an expansive description of symptom evolution, prior interventions, and contextual factors influencing the clinical course. This section enables clinicians to construct a coherent timeline of events precipitating hospitalization, facilitating diagnostic reasoning and interdisciplinary communication among healthcare providers.[8][50] In admission documentation, the HPI emphasizes acute or subacute developments warranting inpatient evaluation, incorporating patient-reported details such as symptom triggers, exacerbations, and responses to outpatient therapies. It typically employs a problem-oriented framework to avoid extraneous historical elements, focusing instead on perturbations from the patient's baseline health status. For instance, in cases of acute abdominal pain, the HPI would delineate the symptom's abrupt onset hours prior to admission, its migratory pattern, and failed attempts at alleviation with over-the-counter analgesics, thereby underscoring the urgency of hospital transfer. This narrative structure supports billing and regulatory requirements under systems like Evaluation and Management (E/M) coding, where a detailed HPI—spanning at least four elements—elevates the documented encounter level.[11][54] Standard components of the HPI are systematically elicited using the mnemonic OLD CARTS to ensure completeness: Onset (sudden or gradual initiation), Location (site and radiation), Duration (persistence and continuity), Characteristics (quality, e.g., sharp versus dull), Aggravating and Relieving factors (modifiers like movement or rest), Timing (patterns or frequency), and Severity (intensity on a scale, often 0-10). These elements guide the interview and documentation, promoting reproducibility and reducing omissions that could impede accurate assessment. Variations may include associated symptoms (e.g., nausea accompanying pain) or pertinent negatives (e.g., absence of fever), integrated chronologically rather than as a checklist.[55][56][57] Effective HPI writing prioritizes prose over bullet points, weaving patient perspectives—such as fears or functional impacts—with objective timelines to argue for the admission's necessity. Challenges include patient recall biases or language barriers, mitigated by corroborating with family or records; incomplete HPIs risk diagnostic delays, as evidenced by studies linking thorough histories to reduced error rates in emergency admissions. In modern practice, electronic health records enforce structured templates to standardize HPI entries, though clinicians must adapt for nuanced cases like chronic exacerbations in readmissions.[54][14][58]Allergies and Intolerances
The allergies and intolerances section of an admission note documents a patient's known hypersensitivity reactions to medications, foods, environmental agents, or other substances to mitigate risks of adverse events during hospitalization. This documentation is essential for guiding prescribing decisions, as failure to record allergies has been linked to medication errors, including anaphylaxis or other severe reactions. Accurate entry supports compliance with standards such as those from the Joint Commission, which mandate visible allergy information in patient records to inform all care providers. No known drug allergies (NKDA) should be explicitly stated when applicable, with verification from the patient, family, or prior records to ensure completeness. Documentation typically includes the specific allergen (e.g., penicillin, latex, shellfish), the nature of the reaction (e.g., urticaria, angioedema, gastrointestinal distress), estimated date of onset if known, and reaction severity (mild, moderate, severe, or life-threatening). Intolerances, distinct from true allergies, are non-immunologic responses such as lactose malabsorption causing bloating or opioid-induced nausea, and should be flagged separately to avoid conflation with immune-mediated events like IgE-dependent anaphylaxis. Adverse drug reactions without immunologic basis, such as idiosyncratic effects, are often recorded in this section but differentiated to prevent over-labeling, which can lead to inappropriate medication avoidance in future care. Best practices emphasize querying patients upon admission about reactions to prior exposures, including timing ("When did this occur?") and subsequent tolerance, while cross-referencing electronic health records or pharmacy data. In electronic systems, entries are made via dedicated allergy modules for alerts during ordering, with updates for any new reactions observed inpatient. Incomplete or erroneous documentation, such as unverified self-reports, contributes to safety events; studies indicate that distinguishing allergy types improves clinical decision support and reduces unnecessary restrictions. Referral to allergists for ambiguous histories, like reported penicillin allergies often found non-immunologic upon testing, is recommended to refine records.Past Medical and Surgical History
The Past Medical and Surgical History (PMH/PSH) section of an admission note systematically documents the patient's preexisting health conditions, prior interventions, and hospitalizations to contextualize the presenting illness and guide diagnostic and therapeutic decisions.[59] This includes chronic illnesses such as hypertension (diagnosed via elevated blood pressure readings exceeding 140/90 mmHg on multiple occasions), type 2 diabetes mellitus (confirmed by fasting glucose levels ≥126 mg/dL or HbA1c ≥6.5%), or chronic obstructive pulmonary disease (evidenced by spirometry showing FEV1/FVC ratio <0.70 post-bronchodilator), with specifics on onset year, severity, complications (e.g., diabetic retinopathy requiring laser therapy), and current control status.[8] Pertinent negatives, such as absence of autoimmune disorders like rheumatoid arthritis (no joint erosions on imaging or positive rheumatoid factor), are often noted to rule out confounding factors.[60] Surgical history enumerates procedures with operative dates, indications, and outcomes; for instance, a coronary artery bypass graft in 2015 for three-vessel disease confirmed by angiography, performed without intraoperative complications but followed by sternal wound infection resolved via antibiotics and debridement.[61] Common entries include appendectomies (typically for acute appendicitis diagnosed by ultrasound or CT showing periappendiceal fat stranding), cholecystectomies (for symptomatic cholelithiasis with gallstones >1 cm on imaging), or total hip replacements (for osteoarthritis with joint space narrowing <2 mm on radiographs).[62] Details on anesthesia type (e.g., general vs. regional) and postoperative recovery, including any adhesions or recurrent hernias, are included to anticipate risks like adhesions complicating future abdominal access.[8] Additional elements cover nonsurgical hospitalizations, such as a 2020 admission for community-acquired pneumonia treated with levofloxacin for 7 days after sputum culture grew Streptococcus pneumoniae, or obstetric history in females (e.g., gravida 3, para 2, with cesarean section in 2018 for failure to progress in labor).[63] Documentation prioritizes relevance to the admission—e.g., emphasizing prior deep vein thrombosis (diagnosed by duplex ultrasound showing noncompressible femoral vein) in a patient with suspected pulmonary embolism—while using structured lists for clarity:- Chronic Conditions: Hypertension since 2010, managed with lisinopril 20 mg daily; no end-organ damage per recent echocardiogram.
- Surgeries: Tonsillectomy at age 8 for recurrent streptococcal pharyngitis; no perioperative issues.
- Hospitalizations: Myocardial infarction in 2018, treated with percutaneous coronary intervention to left anterior descending artery, ejection fraction 45% post-event.[62]
Family and Social History
The family and social history (FH/SH) section in a medical admission note captures hereditary risks and environmental or behavioral factors influencing the patient's health, enabling clinicians to assess genetic predispositions, modifiable lifestyle risks, and social determinants that may affect diagnosis, treatment adherence, and discharge planning. This component is integral to comprehensive patient evaluation, as family history can predict disease susceptibility—for instance, identifying elevated risks for conditions like breast cancer or coronary artery disease through patterns in relatives—while social history reveals barriers such as substance use or unstable housing that complicate care. Guidelines emphasize documenting only pertinent details to avoid redundancy, focusing on conditions relevant to the chief complaint rather than exhaustive genealogies.[59][65][66] Family history documentation prioritizes at least three generations, including parents, siblings, children, and grandparents, with specifics on current ages or age at death, major illnesses (e.g., hypertension, diabetes, cancers with onset ages), and causes of premature death (e.g., myocardial infarction at age 45). Clinicians note hereditary patterns, such as autosomal dominant traits in familial hypercholesterolemia, and exclude non-contributory details; for unavailable information, explicit statements like "family history unknown due to adoption" are required to reflect documentation completeness. This aids risk stratification, informing preventive measures like genetic counseling or screening protocols, as evidenced by studies showing family history's role in early detection of hereditary cancers.[67][68][65] Social history details the patient's lifestyle and support network, typically structured around tobacco use (e.g., pack-years smoked), alcohol consumption (e.g., drinks per week), recreational drug history, occupational exposures (e.g., chemical hazards in manufacturing), living situation (e.g., independent vs. assisted), sexual history if pertinent to infectious risks, exercise, diet, and socioeconomic factors like employment status or access to transportation. Acronyms like OLD CARTS (for substance use) or LOLAS (living situation, occupation, leisure, alcohol, smoking) guide elicitation, highlighting modifiable risks such as smoking's causal link to chronic obstructive pulmonary disease or alcohol's role in liver cirrhosis. In admission contexts, this informs immediate interventions, like nicotine replacement for smokers or social work referrals for homelessness, with documentation tailored to acuity—e.g., abbreviated in emergencies but expanded for chronic disease management.[69][8][63]Current Medications
The Current Medications section of a medical admission note enumerates all pharmacotherapeutic agents a patient is actively using at the time of hospital admission, encompassing prescription drugs, over-the-counter preparations, herbal products, vitamins, minerals, and dietary supplements.[70] This documentation serves as a foundational element of medication reconciliation, a process aimed at creating an accurate inventory to mitigate discrepancies that could precipitate adverse drug events during the inpatient stay.[71] Essential details typically recorded include the generic drug name, formulation, dosage, frequency, route of administration, indication for use, and any recent changes or adherence issues, enabling clinicians to assess potential interactions, duplications, or omissions relative to the presenting condition.[72] Accurate capture requires verification against multiple sources, such as patient interviews, pharmacy records, and outpatient provider notes, as self-reported histories alone often exhibit gaps; for instance, one study found only partial concordance between admission charts and external medication records, with omissions in up to 50% of cases for certain agents.[73] Over-the-counter and non-prescription items are explicitly queried, as they contribute to polypharmacy risks but are frequently underreported.[74] In electronic health records, this section may integrate structured fields or lists to standardize entry, supporting automated alerts for allergies or interactions documented elsewhere in the note.[75] Failure to comprehensively document current medications correlates with heightened error rates, including inappropriate continuations or discontinuations that prolong hospital stays or cause harm; regulatory measures, such as those from the Centers for Medicare & Medicaid Services, mandate this documentation for quality metrics, emphasizing its role in reducing preventable adverse events estimated to affect 7-27% of admissions due to reconciliation failures.[76] [77] Pharmacist involvement in reconciling this list upon admission has demonstrated improvements in completeness, with criteria like dose and indication often initially incomplete in physician-only documentation.[72] Best practices recommend a dedicated "best possible medication history" obtained within 24 hours of arrival, cross-checked for seasonal or episodic use, to inform subsequent orders and discharge planning.[78]Review of Systems
The Review of Systems (ROS) constitutes a structured component of the patient history in an admission note, involving a systematic inquiry into symptoms across multiple body systems through targeted questions directed at the patient. This process aims to elicit subjective reports of signs or symptoms that may not have surfaced in the chief complaint or history of present illness, thereby facilitating a more holistic evaluation of potential comorbidities, undiagnosed conditions, or related health issues upon hospital admission.[79][80] In the context of initial hospital care, a comprehensive ROS is typically required to support evaluation and management service levels, screening for systemic involvement that could influence diagnostic testing, treatment planning, or risk stratification.[81] Standard ROS documentation encompasses at least 10 to 14 organ systems, with questions tailored to common symptoms indicative of dysfunction in each. The following systems are conventionally reviewed:- Constitutional: Inquiries into fever, chills, fatigue, weight changes, or night sweats.
- Eyes: Vision changes, pain, or redness.
- Ears, Nose, Mouth, Throat: Hearing loss, congestion, sore throat, or dental issues.
- Cardiovascular: Chest pain, palpitations, edema, or orthopnea.
- Respiratory: Cough, dyspnea, wheezing, or hemoptysis.
- Gastrointestinal: Nausea, vomiting, diarrhea, abdominal pain, or changes in bowel habits.
- Genitourinary: Dysuria, frequency, hematuria, or incontinence.
- Musculoskeletal: Joint pain, swelling, or muscle weakness.
- Integumentary (Skin/Breast): Rashes, lesions, pruritus, or lumps.
- Neurological: Headaches, dizziness, numbness, seizures, or coordination deficits.
- Psychiatric: Mood changes, anxiety, hallucinations, or sleep disturbances.
- Endocrine: Polyuria, polydipsia, heat/cold intolerance, or thyroid symptoms.
- Hematologic/Lymphatic: Easy bruising, bleeding, lymphadenopathy, or anemia symptoms.
- Allergic/Immunologic: Recurrent infections, hives, or environmental sensitivities.[79][80] Positive responses prompt further elaboration, often using frameworks like onset, location, duration, characteristics, aggravating/alleviating factors, related symptoms, and treatments (OLD CARTS), while pertinent negatives are noted to affirm absence of key symptoms in relevant systems.[80]
Physical Examination
The physical examination in an admission note documents the clinician's objective observations and findings from a systematic hands-on evaluation of the patient, conducted shortly after arrival to establish a baseline for ongoing care. This section contributes essential data to corroborate the history of present illness and guide initial diagnostic and therapeutic decisions, with findings described in concise, reproducible terms to minimize interpretive bias.[11] Documentation typically follows a structured format to ensure completeness, though studies indicate variability in thoroughness, particularly among junior clinicians, where omission of key system reviews occurs in up to 50% of notes.[82] Vital signs form the initial component, routinely recorded to quantify physiological stability: blood pressure (e.g., systolic/diastolic in mmHg), heart rate (beats per minute), respiratory rate (breaths per minute), body temperature (in Celsius or Fahrenheit), and peripheral oxygen saturation (percentage via pulse oximetry). These measurements, often automated or manually obtained, provide immediate indicators of acuity, such as tachycardia signaling potential hypovolemia or infection.[61] Abnormalities prompt further scrutiny, with normal ranges varying by age, sex, and comorbidities (e.g., heart rate 60-100 bpm in adults at rest).[83] The general survey follows, assessing overall appearance, mental status, nutritional state, hydration, and signs of distress, such as alertness via AVPU scale (Alert, Voice, Pain, Unresponsive) or Glasgow Coma Scale for neurological impairment. This holistic overview detects subtle cues like cachexia or pallor absent from self-reported history.[84] Subsequent evaluation proceeds head-to-toe or by organ systems, employing four core techniques: inspection (visual and olfactory assessment), palpation (manual touch for tenderness or masses), percussion (tapping to evaluate underlying density), and auscultation (listening with stethoscope for sounds like breath or heart murmurs). Key systems include:- Head, eyes, ears, nose, and throat (HEENT): Checks for pupillary response, conjunctival pallor, tympanic membrane integrity, nasal patency, and oral lesions or dentition.
- Neck: Palpates lymph nodes, thyroid, and carotid pulses; assesses range of motion and jugular venous distension.
- Chest and lungs: Inspects symmetry, palpates for fremitus, percusses for dullness (e.g., consolidation), and auscultates for wheezes, crackles, or diminished sounds indicating pneumonia or effusion.
- Cardiovascular: Auscultates heart sounds for regularity, murmurs (graded I-VI by intensity), rubs, or gallops; palpates pulses and apex beat.
- Abdomen: Inspects contour, auscultates bowel sounds, percusses for tympany or shifting dullness (ascites), and palpates quadrants for organomegaly, rebound tenderness (peritonitis), or guarding.
- Genitourinary and rectal: External inspection, if indicated, for discharge or masses; digital rectal exam for tone, masses, or occult blood.
- Musculoskeletal and extremities: Evaluates joint swelling, range of motion, edema (pitting graded 1-4+), and peripheral pulses/capillary refill.
- Neurological: Tests cranial nerves, motor strength (0-5 scale), sensation, reflexes (e.g., deep tendon 0-4+), coordination, and gait.
- Skin and integumentary: Notes rashes, ulcers, turgor (for dehydration), or jaundice.[84][83][61]