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Admission Note – How to Write (with Samples)

An admission note is part of medical record that documents the patient’s status, reasons why the patient is being admitted for inpatient care to a hospital or other medical facility and the initial instructions for that patient’s care. This is a note that needs to include all the necessary information that will be helpful in improving the patient’s condition when they are in admission.

To make sure that you do not omit necessary information or include any misleading information, use a sample note. This will make things easier, clearer and simpler for you.

How to Write a Quality Admission Note

1) Start by examining the case

Examining the patient is the very first step that you should take. Check on the symptoms, listen to the complaints that the patient may be having. Make sure you keep a track of all that you are observing especially if the patient is there in person. Check on the blood pressure, heartbeat and temperature among other important information necessary to give guidance for treatment.

2) Take the personal information of the patient

You should take all the necessary information about the patient. That is the name, age, gender, address, phone number, nationality, place of residence and information about the patient’s relatives. The most important part about relative’s information is to mention the contact person.

3) Reason for admission

This is very important part of this note. It should be straightforward and guided by the symptoms that the patient has. You can indicate diagnosis if there is any. Indicate the duration in which the patient has experienced the symptoms.

4) Medication and accommodation

Write down all the prescribed medication as well as the one that the patient has already been given. Also indicate any other form of treatment that the patient has received. Note down the room that the patient has been allocated to and bed number if it applies.

5) Medical history of the patient

Note down the history of the health state of the patient like the general health condition, if the patient has had any accident in the past, medical operations, past hospitalization, allergies and if there has been any progressive disease among other history the patient may be having.

6) Medical history of the family

Note down the health state of the family members of the patient. That includes diseases, hospitalization, and accidents among others.

7) Working conditions of the patient

This is important to note because there are working conditions or environment that contributes to certain symptoms. Get to know and note down the working environment and condition of the patient.

8) Other details

Note down any other detail that is important to observe the patient’s health condition such as weight, appetite vision, hearing and height among others.

Note: do not rely on your memory, always note down as you observe to have a precise information about the patient.

Types of Admission Note

Hospital Admission Note

This is a medical record that documents the patient’s status and reasons why the patient is being admitted in the hospital. It includes the personal information of the patient, the medical examination report, accommodation and relative’s information among other important information about the patient’s status.

Nursing Admission Note

This is a medical record that documents the patient’s status [including history and physical examination findings], reason why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for the patient’s care.

Psychiatric Admission Note

This is an admission note that consists of psychological testing and evaluation that help determine the cause of psychological symptoms and disorders to determine the correct diagnosis.

Newborn Admission Note

This is an admission note for a newborn baby that includes complete information about he physical exam of the baby’s status. This will help the doctors, nurses and other healthcare providers continually look at the health of the baby throughout the hospital stay.

Hospice Admission Note

It is an admission note to a hospice. It includes all the details that show that a patient is eligible for hospice care. This means that a physician certifies the patient as being terminally ill and in need of palliative care.

Labor and Delivery Admission Note

This is an admission note that includes information about the patient’s condition in terms of labor and delivery. It is a maternity admission. Some of the information included in this note is the condition of labor [if it active], how far the patient has dilated, medical history of the patient, other information like weight, heartbeat, blood pressure and all the other important information that is included in admission note.

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