ADMISSION 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]