From the bedside history to a draft H&P.
Vero Scribe writes the admission H&P in your template from your conversation with the patient and family, with their consent, or from your dictation. You review and edit it, then copy it into your EHR.
Admission H&P Template
An admission H&P is the full workup when a patient comes into hospital, from the history to code status and level of care. Copy the free template, see two filled admission notes, and check what each part needs.
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- Word and text downloads
- Two filled examples
Blank admission H&P template
FreeADMISSION HISTORY AND PHYSICAL Patient: [Name] Date of birth or ID: [Identifier] Date and time of admission: [Date, time] Admitting service and attending: [Service, name] Source of history: [Patient, family, EMS, or records; interpreter if used; reliability] Primary care clinician: [Name] Author: [Name, credentials] HISTORY OF PRESENT ILLNESS Chief complaint: [Reason for presentation, in the patient's words] History: [Onset, timeline, associated symptoms, pertinent negatives, treatments tried] Emergency department course: [Arrival vital signs, key results, treatments given, response, consults] PAST HISTORY Medical: [Active and chronic conditions, with severity and baseline values] Surgical: [Procedures and approximate dates] Recent care: [Hospital stays, antibiotics, or procedures in the last 90 days] MEDICATIONS AND ALLERGIES Home medications: [Name, dose, route, frequency, and last dose taken] Reconciliation: [Sources checked, such as patient, bottles, pharmacy record, or family; complete or pending] Allergies: [Drug, food, latex, and contrast allergies, with the reaction to each] FAMILY AND SOCIAL HISTORY Family history: [Relevant conditions in first-degree relatives] Home and supports: [Lives alone or with others, stairs, help at home] Baseline function: [Mobility, walking aid, daily activities, cognition] Substance use: [Tobacco, alcohol with amount and last drink, other substances] Work and exposures: [Occupation, travel, other exposures] REVIEW OF SYSTEMS Review of systems: [Pertinent positives and negatives by system] PHYSICAL EXAMINATION Vital signs: [Temperature, HR, BP, RR, SpO2 with oxygen, weight] Examination: [Findings by system] DATA Labs: [Results, with abnormal values and baselines for comparison] Imaging: [Studies and findings] ECG: [Rhythm, intervals, change from previous] Microbiology: [Cultures sent, before or after antibiotics] ASSESSMENT AND PLAN Summary: [Age, sex, key history, presentation, and working diagnosis in one or two sentences] Problem 1: [Diagnosis, supporting findings, severity, and plan] Problem 2: [Diagnosis, supporting findings, and plan] Chronic conditions: [Each home medication continued, held, or changed, and why] Prophylaxis: [VTE, plus falls, delirium, pressure injury, or stress ulcer if indicated] Diet and lines: [Diet, or NPO with reason; IV access and other devices] GOALS OF CARE AND DISPOSITION Code status: [Decision, who took part in the discussion, and capacity] Goals of care: [What matters to the patient, named decision-maker, advance directive] Level of care: [Ward, telemetry, step-down, or intensive care; observation or inpatient] Discharge planning: [Expected length of stay, barriers, early referrals] Signed: [Clinician name, credentials, date and time]
Use it for
- Medical admissions
- Observation stays
- Direct admissions
- Transfers between hospitals
- Teaching services
Two filled examples. Every part, filled in.
Each one follows the template. Use them to judge how much detail every part needs.
Admission H&P: sepsis from a urinary source
Medical admission from the emergency department
History of present illness
Chief complaint, per her daughter: “confused and feverish since last night.” 82-year-old woman; history from her daughter, who lives with her, and the emergency record, as the patient is drowsy and gives only part of it. Two days of burning and frequent urination, then fever to 38.9 °C (102.0 °F) at home, left flank pain, poor intake, one vomit, and new confusion since last evening. No cough, shortness of breath, diarrhea, rash, or headache. Emergency course: T 38.9 °C (102.0 °F), HR 112, BP 88/52, RR 24, SpO2 95% on room air; lactate 3.4 mmol/L. Blood and urine cultures, then ceftriaxone 1 g IV within the hour. Lactated Ringer’s 1.75 L (30 mL/kg) over 2 hours: BP 108/62, HR 96, repeat lactate 1.8 mmol/L. Lungs clear after fluids.
Past history
Type 2 diabetes, last A1c 7.8%. Hypertension. Chronic kidney disease stage 3a, baseline creatinine 1.2 mg/dL (106 µmol/L). Osteoarthritis. Mild memory problems, independent at home. Hysterectomy; right knee replacement. No hospital stays or antibiotics in the last 90 days.
Medications and allergies
Metformin 500 mg twice daily, lisinopril 10 mg daily, amlodipine 5 mg daily, atorvastatin 20 mg daily, acetaminophen 500 mg as needed; all last taken yesterday morning. Reconciliation complete: her daughter brought the bottles, matched to the pharmacy record. Allergies: penicillin, a rash as a child, with no hives, swelling, or breathing trouble; took cephalexin 2 years ago without a reaction.
Family and social history
Family history noncontributory. Lives with her daughter in a house with 3 steps at the entrance. Walks with a cane; independent in bathing and dressing; her daughter manages shopping and medicines. Never smoked; no alcohol.
Review of systems
Positive: fever, burning and frequent urination, left flank pain, nausea with one vomit, poor intake, confusion. Negative: cough, chest pain, shortness of breath, abdominal pain, diarrhea, rash, headache, neck stiffness, falls.
Physical examination
After fluids: T 38.4 °C (101.1 °F), HR 96, BP 108/62, RR 20, SpO2 96% on room air. Weight 58 kg (128 lb). Drowsy but rousable; oriented to person only, inattentive; CAM positive. Her daughter says she was fully oriented 2 days ago. Dry mucous membranes. JVP not visible. Lungs clear. Heart regular, no murmur. Abdomen soft, tender above the pubic bone; left costovertebral angle tenderness. No neck stiffness. Skin warm, no rash; sacrum and heels intact.
Data
White count 16.4, mostly neutrophils. Hemoglobin 12.1 g/dL (121 g/L). Platelets 210. Sodium 134, potassium 4.6 mmol/L. Creatinine 1.8 mg/dL (159 µmol/L); baseline 1.2 mg/dL (106 µmol/L). Glucose 12.4 mmol/L (223 mg/dL). Lactate 3.4, then 1.8 mmol/L. Urinalysis: leukocyte esterase and nitrite positive, many white cells. Chest x-ray clear. ECG: sinus tachycardia, no acute changes. Two sets of blood cultures and a urine culture, all drawn before antibiotics, pending.
Assessment and plan
82-year-old woman with diabetes and chronic kidney disease, admitted with sepsis from a urinary source, most likely left pyelonephritis, with low blood pressure and a raised lactate that responded to fluids, acute kidney injury, and delirium. 1. Sepsis, likely pyelonephritis: ceftriaxone 1 g IV every 24 hours, chosen per the local antibiogram; narrow when cultures return. Renal ultrasound today to rule out obstruction. Vital signs per the sepsis pathway. 2. Acute kidney injury on chronic kidney disease, likely from sepsis, poor intake, and lisinopril: hold lisinopril and metformin; avoid NSAIDs and IV contrast; intake and output; creatinine in the morning. 3. Delirium: treat the infection; glasses and hearing aids on, her daughter at the bedside when possible, reorientation, sleep at night; avoid sedatives and anticholinergic drugs. 4. Type 2 diabetes: correction insulin per protocol, glucose target 7.8 to 10.0 mmol/L (140 to 180 mg/dL). 5. Hypertension: hold amlodipine while BP is low; continue atorvastatin. Prophylaxis: heparin 5,000 units subcutaneously every 12 hours, as estimated creatinine clearance is about 22 mL/min; falls, delirium, and pressure injury precautions; no stress ulcer prophylaxis needed. Diet: clear fluids, advance as tolerated. Two peripheral IVs; no urinary catheter, bladder scan if no void in 6 hours.
Goals of care and disposition
Code status: do not resuscitate and no intubation; otherwise full medical treatment, including vasopressors and intensive care if needed. Taken from her advance directive and confirmed with her daughter, her named decision-maker; the patient can’t take full part today because of delirium. Level of care: inpatient, medical ward; vital signs hourly for 4 hours, then every 4 hours if stable; rapid response review if BP falls despite fluids or lactate rises. Discharge planning: expected stay 3 to 5 days; physical and occupational therapy once alert; her daughter can support her at home.
Admission H&P: chest pain for observation
Observation admission from the emergency department
History of present illness
Chief complaint: “pressure in my chest walking up the stairs.” 54-year-old man with 2 episodes of central chest pressure in the last 24 hours, each while climbing stairs, lasting 5 to 10 minutes, spreading to the left arm, with mild breathlessness, and easing with rest. Pain-free since. No pain at rest, fainting, or palpitations. No recent illness, long travel, or leg swelling. Emergency course: arrived pain-free; ECG without ischemic changes; high-sensitivity troponin below the 99th percentile at 0 and 2 hours with no significant change, per the local pathway. HEART score 5. Aspirin 325 mg chewed.
Past history
Hypertension for 6 years. High cholesterol found 2 years ago, never treated. Appendectomy as a teenager. No previous heart testing.
Medications and allergies
Amlodipine 5 mg daily, last taken this morning. No other medicines or supplements. Reconciliation complete: his list matched to the pharmacy record. No known drug allergies.
Family and social history
Father had a heart attack at 58; mother has hypertension. Lives with his wife; works as an office manager. Smokes a pack a day, 20 pack-years. Alcohol 2 drinks a week. No cocaine or other stimulant use. Independent and active.
Review of systems
Positive: exertional chest pressure, mild breathlessness with the episodes. Negative: breathlessness lying flat, leg swelling, cough, fever, heartburn, abdominal pain, leg pain on walking, focal weakness.
Physical examination
T 36.7 °C (98.1 °F), HR 76, BP 146/88 right arm and 144/86 left arm, RR 14, SpO2 98% on room air. Weight 88 kg (194 lb), BMI 28.7. Comfortable. JVP normal. Heart regular, no murmur or rub. Lungs clear. Chest wall not tender. Abdomen soft. Pulses equal in all four limbs. No leg swelling.
Data
ECG: sinus rhythm 74, normal intervals, no ST or T-wave changes; unchanged at 2 hours. High-sensitivity troponin 8 and 9 ng/L at 0 and 2 hours, below the 99th percentile for the assay. Hemoglobin 14.6 g/dL (146 g/L); electrolytes and creatinine normal. LDL 4.1 mmol/L (159 mg/dL). A1c 5.8%. Chest x-ray normal.
Assessment and plan
54-year-old man with hypertension, untreated high cholesterol, smoking, and a family history of early coronary disease, with new exertional chest pressure. Myocardial infarction ruled out by serial troponin; possible new-onset angina; HEART score 5, intermediate risk. 1. Chest pain: telemetry; aspirin 81 mg daily; nitroglycerin 0.4 mg under the tongue as needed, with an ECG and troponin for any new pain. Coronary CT angiography or stress testing tomorrow, per the local chest pain pathway; cardiology review if abnormal. 2. High cholesterol: start atorvastatin 40 mg daily; adjust after testing. 3. Hypertension: continue amlodipine; review the target after testing. 4. Smoking: advised to stop; nicotine patch 21 mg a day started, and he accepted a referral to a quit program. Prophylaxis: pharmacologic VTE prophylaxis not indicated, as he is walking independently and at low risk. Diet: heart healthy; fasting and no caffeine before testing, per protocol. One peripheral IV.
Goals of care and disposition
Code status: full code, discussed with the patient, who has capacity. Goals: wants to know whether this is his heart, and to get back to work. Level of care: observation, telemetry bed. Discharge planning: home tomorrow if testing is normal, with family physician follow-up in 1 to 2 weeks; cardiology follow-up if abnormal.
What goes in each part.
History of present illness
The story from the first symptom to the decision to admit, including what happened in the emergency department.
- The chief complaint in the patient’s words
- Timeline, associated symptoms, and pertinent negatives
- Who gave the history, and how reliable it is
- Emergency department vital signs, results, treatments, and the response
Avoid: Pasting the emergency department note. Take the history again and write it in your own words, noting anything that differs.
Medications and allergies
Medication reconciliation starts here: each home medication, and how you know the list is right.
- Name, dose, route, frequency, and the last dose taken
- Sources checked: patient, bottles, pharmacy record, family
- Reconciliation complete or pending, and who will finish it
- Allergies with the reaction, such as rash, hives, or anaphylaxis
Avoid: An allergy with no reaction. “Penicillin” could mean a childhood rash or anaphylaxis, and the difference changes the antibiotic.
Family and social history
Baseline function and supports, which shape the discharge plan from day 1.
- Who the patient lives with, and the home setup
- Baseline mobility, walking aids, and daily activities
- Baseline cognition, from the patient or family
- Tobacco, alcohol with the last drink, and other substances
Avoid: Leaving out baseline function. Without it, nobody can tell whether the patient is back to normal.
Assessment and plan
A summary statement, then a numbered plan for each problem, active and chronic.
- Age, key history, presentation, and working diagnosis in one or two sentences
- Each problem with its severity and supporting findings
- Home medications continued, held, or changed, with the reason
- Prophylaxis, diet, and lines
Avoid: Tests listed without the question each one answers. Tie every order to a problem.
Goals of care and disposition
What the patient wants from this admission, and where they should be cared for.
- Code status, and who took part in the discussion
- The patient’s named decision-maker and any advance directive
- Level of care: ward, telemetry, step-down, or intensive care
- Expected length of stay and early discharge needs
Avoid: Writing “full code” by default. Record that you asked, who answered, and what they said.
Common mistakes, and how to avoid them.
A medication list nobody checked
A list copied from an old record carries stopped drugs and misses new ones. Check at least two sources, say which, and record the last dose taken.
Results without baselines
Write the baseline creatinine, hemoglobin, or oxygen need next to today’s value. “Creatinine 1.8” means little until you know it was 1.2 last month.
Level of care without criteria
Say why the patient is on the ward and what would trigger a move up, such as a falling blood pressure or a rising lactate.
Not recording when cultures were drawn
Note whether cultures were taken before the first antibiotic dose. It changes how the team reads a negative result.
Holding medications with no restart plan
When you hold a home medication, write why and when to restart it, so it doesn’t stay off through discharge.
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Frequently asked questions.
What goes in an admission H&P?
The source of the history, chief complaint, HPI and emergency course, past history, reconciled medications, allergies with reactions, family and social history with baseline function, review of systems, exam, results, a plan by problem, prophylaxis, code status, and the level of care.
Is an admission note the same as an admission H&P?
Usually, yes. Some teams call a shorter version an admission note, but both need the same core: history, exam, results, a plan by problem, and code status.
How do you document medication reconciliation on admission?
List each home medication with its dose and the last dose taken, name the sources you checked, such as the patient, the bottles, and the pharmacy record, and say whether reconciliation is complete. Then say in the plan whether each one is continued, held, or changed.
Do I need to document code status on every admission?
Yes. Ask on admission and record who you spoke with, the decision, and any advance directive or named decision-maker. If the patient can’t take part, say why and who spoke for them.
Is this admission H&P template free?
Yes. Copy it, or download it as a Word or text file. No account needed.
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