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Clinical noteHospital Medicine

Admission H&P

Inpatient admission history and physical with pre-admission course, complete history, admission data, problem-based plan, prophylaxis, code status, and disposition.

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What’s in this template

16 sections, in the order they appear in the finished document.

  1. 1Chief ComplaintParagraph
  2. 2History of Present IllnessParagraph
  3. 3ED / Pre-Admission CourseBullets
  4. 4Past Medical HistoryBullets
  5. 5Past Surgical HistoryBullets
  6. 6Home MedicationsBullets
  7. 7AllergiesBullets
  8. 8Family HistoryBullets
  9. 9Social History & Baseline FunctionBullets
  10. 10Review of SystemsBullets
  11. 11Physical ExaminationAuto
  12. 12Labs, Imaging & DiagnosticsBullets
  13. 13Assessment & PlanAuto
  14. 14FEN, Prophylaxis & LinesBullets
  15. 15Code Status & Goals of CareParagraph
  16. 16Level of Care & Anticipated DispositionBullets

“Auto” sections use whichever format reads most clearly for what was discussed: prose or a list.

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