ADULT ADMISSION HISTORY AND PHYSICAL
Patient identifiers / encounter / admitting service:
Admission date and time / examination time / entry time:
Author / role / supervising clinician where applicable:
Sources, dates, interpreter and limits of the history:

CHIEF CONCERN AND HISTORY OF PRESENT ILLNESS
Patient's reason for seeking care:
Onset, sequence, severity, associated symptoms and relevant negatives:
Baseline function / change from baseline:
Previous evaluation and treatment; actual response:
ED course: administered treatment versus orders awaiting administration:
Reason for admission now:

BACKGROUND
Past medical conditions; source and current relevance:
Operations / admissions / relevant prior investigations and dates:
Family history relevant to this presentation:
Living situation, support, function, occupation and relevant exposures:
Tobacco, alcohol and other substance use as elicited:
Medicines actually taken: name, dose, route, frequency, last dose, source:
Medication discrepancies / verification owner / checkpoint:
Allergies and reactions; source and unresolved details:

REVIEW OF SYSTEMS
Questions asked; patient-reported positives and pertinent negatives:
Systems or questions not assessed / reason:

PHYSICAL EXAMINATION
Examiner and examination time:
Observations: time, value, units, method, oxygen device and flow if used:
Actual general, respiratory, cardiovascular and other relevant findings:
Not examined / unable to assess / declined; reason and next step:

INVESTIGATIONS AND CLINICAL REASONING
Dated results; preliminary/final status; historical versus current:
One-sentence summary of presentation and admission need:
For each problem:
- Assessment / working diagnosis / degree of certainty:
- Supporting findings, alternatives and missing information:
- Planned action and rationale:
- Order / administration / result / review status:
- Responsible person / checkpoint / escalation or backup route:

ADMISSION PLAN AND FOLLOW-UP
Medication reconciliation and corresponding orders:
Relevant monitoring, diet, mobility and prevention orders / record reference:
Goals-of-care discussion and actual resuscitation-order status:
Communication, access or support needs:
Disposition barriers / anticipated coordination:
Outstanding results, assessments and verification tasks with owners:
Receiving team acceptance if responsibility transfers:
Author authentication; required supervisory review:
Saved narrative, structured fields and task list checked for agreement: