Sample Admission Notes for the Most Common Conditions

Author: V. Dimov, M.D.

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 SOB, CHF
Admission Note for Chest Pain
Admission Note for Syncope
Admission Note for CP, 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

GI

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

Nephrology

Admission Note for ESRD, HD, AVF

Endo

Admission Note for DKA, ICU

Hem/Onc

Admission Note for Sickle Cell Crisis

Rheum

Admission Note for Back Pain

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: 09/04/2008