Structured template for documenting patient admission.
Admission notes provide a comprehensive record of a patient's presentation, history, examination findings and initial management plan. They form the foundation of the clinical record and guide ongoing care.
DATE: ___________ TIME: ___________ ADMITTING CLINICIAN: ___________________ WARD/LOCATION: ________________________ PATIENT: ______________________________ DOB: _____________ NHS No: ____________ SOURCE OF REFERRAL: ___________________ REASON FOR ADMISSION: _________________ PRESENTING COMPLAINT: [In patient's own words] HISTORY OF PRESENTING COMPLAINT: [Onset, duration, character, associated symptoms] PAST MEDICAL HISTORY: 1. 2. 3. PAST SURGICAL HISTORY: 1. 2. MEDICATIONS: 1. 2. 3. ALLERGIES: ____________________________ Reaction: _____________________________ FAMILY HISTORY: _______________________ SOCIAL HISTORY: Occupation: ___________________________ Smoking: _____ Alcohol: _______________ Living situation: ______________________ Functional status: _____________________ SYSTEMS REVIEW: CVS: _________________________________ RS: __________________________________ GI: __________________________________ CNS: _________________________________ Other: _______________________________ EXAMINATION: General: ______________________________ Vital signs: HR ___ BP ___/__ RR ___ Temp ___ SpO2 ___ Weight: ______ NEWS: ________ Cardiovascular: ________________________ Respiratory: __________________________ Abdomen: _____________________________ Neurological: _________________________ Other: _______________________________ INVESTIGATIONS: Bloods requested: _____________________ Imaging requested: ____________________ Results available: _____________________ IMPRESSION: [Clinical diagnosis / differential] MANAGEMENT PLAN: 1. 2. 3. ESCALATION/CEILING OF CARE: _______________________________________ SIGNATURE: ____________ DATE: _________ NAME (print): __________________________ GMC/NMC No: ___________________________