Sample Admission Notes for the Most Common Medical Conditions

The sample notes provide most of the questions to ask while collecting patient history, the common physical findings, and the typical assessment and plan. Having the basics pre-written in front of you may help you discover some unusual and challenging findings in atypical clinical situations.

If you want to print a note, just select the text with the mouse, and choose "print selection" from the print menu.

Cardiology

Admission Note for Shortness of Breath (SOB), CHF
Admission Note for Chest Pain
Admission Note for Syncope
Admission Note for Chest Pain, ICU

Pulmonology and Critical Care

Admission Note for SOB, Asthma
Admission Note for SOB, Pneumonia
Admission Note for Ventilated Patient, ICU
Admission Note for Alcohol or Drug Overdose

Gastroenterology (GI)

Admission Note for N/V/D
Admission Note for GI Bleed
Admission Note for Abdominal Pain

Nephrology

Admission Note for ESRD, HD, AVF

Endocrinology

Admission Note for DKA, ICU

Hematology/Oncology

Admission Note for Sickle Cell Crisis

Rheumatology

Admission Note for Back Pain

Infectious Diseases (ID)

Admission Note for Leg Pain
Admission Note for Infection
Admission Note for Septic Shock, ICU
Admission Note for Pelvic Pain, PID, GU Sx

Neurology

Admission Note for Dizziness
Admission Note for Seizures
Admission Note for Change in MS

References

Audio/Video

SOAP Note 101 Series. The Texas Tech Medcast: A podcast series designed for first-year medical students who are learning how to write an effective patient note for a medical record.

Further Reading

Admission Note - Universal Note
Progress Note - SOAP Format
Procedure Note
Happy's Hospitalist Order Sets, 08/2008.
EMR (Epic) primer: Our Most Expensive Typing Pool. Dr. Wes, 09/2008.
Collecting History: Pulling Teeth. FatDoctor, 01/2008.

Published: 01/06/2004
Updated: 03/30/2010

No comments:

Post a Comment

Post a Comment