Hospitalist Admission Note Template

TL;DR

• When to use: New admissions, transfers from ED or other facilities
• What it includes: CC, HPI, PMH, assessment, problem-based plan

Template

ADMISSION H&P

Date/Time: [XX/XX/XXXX] [XX:XX]
Attending: [XX]
Admitting Service: Hospital Medicine

CHIEF COMPLAINT:
[XX] - use patient's words when possible

HISTORY OF PRESENT ILLNESS:
[XX]-year-old [male/female] with history of [relevant PMH] who presents with [CC] x [duration].

Onset: [sudden/gradual], began [timeframe]
Location: [if applicable]
Quality: [description]
Severity: [XX/10]
Timing: [constant/intermittent/progressive]
Aggravating factors: [XX]
Alleviating factors: [XX]
Associated symptoms: [XX]

Pertinent positives: [XX]
Pertinent negatives: [XX]

ED course: [vitals on arrival, interventions, response]

REVIEW OF SYSTEMS:
Constitutional: [fever, chills, weight change, fatigue]
HEENT: [headache, vision changes, sore throat]
Cardiovascular: [chest pain, palpitations, edema]
Respiratory: [dyspnea, cough, wheezing]
GI: [nausea, vomiting, diarrhea, constipation, abdominal pain]
GU: [dysuria, frequency, hematuria]
MSK: [joint pain, weakness]
Neuro: [numbness, tingling, focal weakness, confusion]
Psych: [depression, anxiety]
[All other systems reviewed and negative unless noted above]

PAST MEDICAL HISTORY:
1. [XX]
2. [XX]
3. [XX]

PAST SURGICAL HISTORY:
1. [XX] - [year]
2. [XX] - [year]

ALLERGIES:
[Drug]: [reaction type]
NKDA: [ ]

HOME MEDICATIONS:
1. [Medication] [dose] [frequency]
2. [Medication] [dose] [frequency]
3. [Medication] [dose] [frequency]

FAMILY HISTORY:
Mother: [XX]
Father: [XX]
Siblings: [XX]
[Pertinent cardiac, cancer, diabetes, clotting disorders]

SOCIAL HISTORY:
Living situation: [XX]
Occupation: [XX]
Tobacco: [never/former/current] - [pack-years if applicable]
Alcohol: [none/social/heavy] - [drinks per week]
Substances: [none/details]
Advance directives: [full code/DNR/DNI/POLST on file]

PHYSICAL EXAMINATION:
Vitals: T [XX] | HR [XX] | BP [XX/XX] | RR [XX] | SpO2 [XX]% on [RA/supplemental O2]
General: [alert, oriented, comfortable/in distress]
HEENT: [NCAT, PERRLA, MMM, no JVD]
Cardiovascular: [RRR, no murmurs/rubs/gallops]
Respiratory: [CTAB, no wheezes/rales/rhonchi]
Abdomen: [soft, NT/ND, BS+, no masses]
Extremities: [no edema, pulses 2+ bilaterally]
Neuro: [A&Ox3, CN II-XII intact, strength 5/5 throughout, sensation intact]
Skin: [warm, dry, no rashes]

LABORATORY DATA:
CBC: WBC [XX] | Hgb [XX] | Plt [XX]
BMP: Na [XX] | K [XX] | Cl [XX] | CO2 [XX] | BUN [XX] | Cr [XX] | Glucose [XX]
[Additional relevant labs]

IMAGING/STUDIES:
[Study type] ([date]): [key findings]

ASSESSMENT:
[XX]-year-old [male/female] with [relevant history] admitted for [primary diagnosis].

Problem List:
1. [Primary diagnosis]
2. [Secondary diagnosis]
3. [Chronic condition - management during hospitalization]

PLAN:

Problem #1: [Diagnosis]
Assessment: [Clinical reasoning, severity, likely etiology]
Plan:
- [Diagnostic workup]
- [Treatment/intervention]
- [Monitoring]
- [Consults if needed]

Problem #2: [Diagnosis]
Assessment: [XX]
Plan:
- [XX]

Problem #3: [Chronic condition]
Assessment: [Stable/unstable, current management]
Plan:
- [Continue/hold/adjust home medications]

PROPHYLAXIS:
- DVT: [SCDs/pharmacologic/contraindicated because XX]
- GI: [PPI if indicated/not indicated]
- Glycemic control: [home regimen/sliding scale/insulin drip]

DISPOSITION:
- Anticipated LOS: [XX] days
- Discharge planning: [home/SNF/rehab] with [services]
- Goals of care discussed: [yes/no/deferred]

Code status: [Full code/DNR/DNI]

[Provider signature block]

Why This Works

Problem-based A&P structure: Each problem gets its own assessment and plan section. This forces explicit clinical reasoning and ensures nothing gets missed. It also maps directly to billing requirements.

Comprehensive but templated ROS/PE: Listing all systems prevents omissions while allowing quick documentation of pertinent findings. Negative findings matter as much as positives for ruling out differentials.

Upfront code status and disposition: Placing these at the end ensures the conversation happens early. This prevents delays in goals-of-care discussions and facilitates discharge planning from day one.

Filled Example

[SYNTHETIC EXAMPLE - Not a real patient]

ADMISSION H&P

Date/Time: [XX/XX/XXXX] 14:30
Attending: [XX]
Admitting Service: Hospital Medicine

CHIEF COMPLAINT:
"Shortness of breath getting worse over the past 3 days"

HISTORY OF PRESENT ILLNESS:
72-year-old male with history of HFrEF (EF 35%), HTN, T2DM who presents with progressive dyspnea x 3 days.

Onset: Gradual, began 3 days ago
Quality: Dyspnea on exertion progressing to dyspnea at rest
Severity: Unable to walk to bathroom without stopping
Aggravating factors: Lying flat, minimal exertion
Alleviating factors: Sitting upright, supplemental O2
Associated symptoms: Lower extremity swelling, 8 lb weight gain, orthopnea (now sleeping in recliner)

Pertinent positives: Dietary indiscretion over holidays, missed 2 doses of furosemide
Pertinent negatives: No chest pain, no fever, no cough, no PND

ED course: Initial SpO2 88% on RA, improved to 94% on 2L NC. Given IV furosemide with good diuretic response.

[...remainder of filled example abbreviated for length...]

ASSESSMENT:
72-year-old male with HFrEF admitted for acute decompensated heart failure, likely triggered by dietary indiscretion and medication non-adherence.

Problem #1: Acute decompensated heart failure (HFrEF)
Assessment: NYHA Class III, volume overloaded on exam, BNP elevated at 1,850
Plan:
- IV furosemide [dose based on home diuretic and renal function], goal net negative 1-2L/day
- Daily weights, strict I/O
- Fluid restriction 1.5L/day
- Continue home carvedilol, lisinopril
- Echo if no improvement in 48 hours
- Cardiology consult if refractory to diuresis

[...additional problems...]

Code status: Full code (confirmed with patient)

Checklist

• CC captures reason for admission in patient’s words
• HPI includes timeline, pertinent positives/negatives, ED course
• All home medications listed with doses and frequencies
• Code status documented and discussed
• Problem list is specific with ICD-10 billable diagnoses
• Each problem has explicit assessment and plan
• DVT prophylaxis addressed
• Discharge planning initiated

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Last reviewed: 2026-01-20. Clinical content based on society guidelines, FDA labeling, and pivotal trials available at review date. Verify against current sources before clinical use.