Patient Admission 📝

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🔍 Before You Start

  • Check triage/referral details or reason for admission.
  • Note any red flags (e.g. chest pain, shortness of breath, confusion).
  • Ensure patient is stable—address ABCs if unwell.

🗣️ History

  • Presenting complaint – what brought them in today?
  • History of presenting complaint – timeline, severity, progression.
  • Past medical history – major illnesses, surgeries, hospitalisations.
  • Drug history – current meds, allergies (including reactions).
  • Family history – relevant hereditary conditions.
  • Social history – smoking, alcohol, living situation, supports.
  • Systems review – pick up anything missed.

🩺 Examination

  • Vitals: HR, BP, Temp, RR, O2 sats.
  • General appearance: well/unwell, cachectic, jaundice, confusion.
  • Systematic exam: Focus based on complaint but examine broadly.
  • Neurological screen if altered or relevant complaint.

🧪 Initial Orders

  • IV access and admission bloods: FBC, U&E, CRP, LFTs, Coag, Trop, Glucose, ± others.
  • ECG if cardiac history, palpitations, chest pain.
  • Urinalysis ± culture.
  • CXR if respiratory complaint or fever.
  • Cultures if signs of infection.

📝 Documentation

  • Clearly document history, exam, initial impression.
  • Working diagnosis and differentials.
  • Plan: investigations, management, referrals.
  • Escalation plan / ceiling of care - discuss with seniors (e.g. for frail or elderly).

📦 Other Essentials

  • Medication reconciliation—match chart with patient's meds.
  • Write up regular meds + PRN analgesia/laxatives/antiemetics.
  • Write up admission medications (e.g. IV fluids, antibiotics).
  • Fluid balance: oral intake? Need IV fluids?
  • Notify team if complex or unstable.

Specialty-Specific Admission Guide

Select a specialty for focused history, examination, and investigations

Select a specialty above to view specialty-specific admission guidance

Note Template

Ready-to-use clinical note structure

🕒 21 / 11 / 2025 — 03:10

Medical / Surgical Admission Note
Patient: [age] [sex]
Admission Dx: [reason for admission]
PMHx: [relevant comorbidities / secondary diagnoses]

🧾 Hx:
• Presenting complaint and history
• Past medical and surgical history
• Allergies and medications
• Social history and support

🩺 Exam:
• Full systems examination
• Vitals: HR __ BP __ Temp __ RR __ SpO₂ __
• Mental status and GCS

📋 Impression:
Working diagnosis and differential

📌 Plan:
• Initial investigations and bloods
• Imaging and specialist referrals
• Treatment commenced
• Monitoring and escalation plan

👤 [Your Name], [Role]
IMC: _______
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