Hospital Admission
last authored: July 2011, David LaPierre
last reviewed: March 2012, Babatunde Awokola
Introduction
The hospital admission summarizes the findings from the history and physical exam, as well as provides an outline of investiations during hospitalization. Lastly, it summarizes the above and provides a plan of action for the coming days.
The admission assists the health care team in understanding the patient and threats to their health, as well as determining the best approach for treatment. It is also crucial in ensuring continuity of healthcare especially if the health team members change.
Date and time are essential.This can be life saving for the patient and very helpful to the author if a lawsuit or investigation arises.
History of Presenting Illness
This section describes the reason for coming to hospital. Where possible, it is helpful to use the patient's own words; "my abdomen felt as though it were stabbed with a knife".
Follow the timeline of events as they unfolded, including symptoms, help sought, investigations, and treatments leading to hospitalization.
Ensure pertinent negatives are also included.
Past Medical History
Current and past conditions and diseases should be listed, with brief information given as appropriate. For example:
- myocardial infarction x 2 (1996, 2002); CABG 2002
- chronic renal failure; baseline creatinine 260
Past Surgical History
These should be listed. Many clinicians include obstetrical history, including vaginal births, here.
Family History
An account of diseases that run in the family or passed on from one generation to the other. It is helpful to include pertinent negatives, stating, for example, if there is no cardiovascular disease history in someone suspected of having myocardial infarction, or stating there is no cancer history in someone with weight loss.
Medications
Endeavour to be as complete as possible, with dose and timing given. Include prescriptions such as puffers and patches, as well as over the counter medications. If the patient does not have a sufficient listing, get in touch with their health care provider or pharmacy, as possible.
Allergies
List allergies and reactions.
Social History
Most clinicians include items such as:
- marital status, number of children
- occupation
- relevant information about housing
- smoking
- alcohol (number and type of drinks)
- illegal drugs
- hobbies, as appropriate
Illness Experience
The ilness experience describes the patient's own understanding, beliefs, and desires. It may be discussed, and recounted, using the acronym FIFE:
- fears - regarding this illness ,what does the patient fear most?
- ideas - what does the patient feel caused the problem?
- functional disability- what has this prevented him / her from doing?
- expectations- what does he/ she want from the health team?
It is helpful to ask, in this context, what the patient would like in the case of deteriorating condition to the point of intubation or cardio-pulmonary resuscitation (CPR) - that is, their code status.
Review of Systems
It is helpful to review a number of symptoms that help illustrate the patient's overall health.
- General: weight loss, fevers, chills, night sweats, falls
- Head, Eyes, Ears, Nose, and throat: changes in vision or hearing; hoarseness
- Chest: pain, cough, shortness of breath
- Abdomen: pain, nausea, vomiting, constipation, diarrhea, melena, hematochezia
- Genitourinary: incontinence, dysuria, discharge, bleeding
- Musculoskeletal: Joint pain
- Skin: changes or suspicious lesions
Physical Exam
Summarize the key findings. Be thorough but concise.
Appearance: alert? oriented? pleasant? responding appropriately?
Vital signs.
ENT: negative suffices
Chest: clear, good breath sounds across lung fields.
Heart sounds: Normal? extra sounds or murmurs? JVP? edema? peripheral pedal pulses? carotid or femoral bruits?
Abdomen: obese? soft? guarding? tenderness? masses?
MSK/CNS: grossly normal? movements x 4 limbs? power/sensory appear N? cranial nerves?
Investigations
Summarize bloodwork and imaging. Include pertinent positives and negatives. Mention outstanding tests.
Impression
Summarize the pertinent history, physical and laboratory investigations in 1-2 sentences.
Mention the list of problems.
Provide a differential diagnosis.
Plan
Based upon the list of problems, describe the plan of action, including steps already taken. Discuss medications, IV fluids, and other treatments. Describe upcoming tests used to hone in on the differential diagnosis. Provide a description of expected outcomes and disposition once discharged from hospital.
Resources and References
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