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Admission Note/Consult:

Consultation Note or New Admission Note:


1. Identification (ID): Name, age, gender.
 
2.
Reason for Referral (RFR) or Chief Complaint (CC): Why are you seeing them, how did they present?

 

3. Relevant Past Medical/Surgical Hx (Specific to CC, e.g. if CC is CHF then include CABG, HTN, Dyslipid hx etc..): Include how conditions are managed and any scores pertaining e.g. CHF include EF, A.fib include CHADS2 score etc.. This helps frame the patient.
 
4.
History of Presenting Illness (HPI):

  • Establish baseline:

  • Events leading to presentation:

  • Location:

  • Management: what have you taken, how was this managed previously.

  • Onset:

  • Precipitating/relieving factors:

  • Quality:

  • Radiation:

  • Severity:

  • Timing:

  • Review of Systems:

 
5.
Past Medical History (PMHx): Any other less pertaining medical hx

 

5. Past Surgical History (PSHx): Like PMHx. Include:

  • When was the surgery?

  • Was it scheduled or emergent?

  • Who performed the surgery and at which hospital?

  • Were there any complications?

  • What type of anesthetic was used (general, epidural, spinal, local)

 
6.
Family History: Similar conditions or others that could lead to such complications.
 
7.
Medications: Name, Dose, Route, Frequency, Reason for taking.
 
8.
Allergies: Medication Allergies, What type of reaction?
 
9.
Social History: Occupation, marital status, and substance use.

 

10. Immunization History

 

11. Physical Exam, Starting with Vitals. Include any bedside investigations e.g. point of care ultrasound here.

 

12. Investigations performed so far and their results

 

 

 

 

 

 

 

 

 

13. Assessment: Your Impression, most likely dx and other DDx.

 

14. Issues & Plan:

  • Issues list (Consider Bio, Psycho, Social) & investigation & managment for each issue

  • Disposition, where should they go and whats preventing them from going home?

Discipline-specific Addendum

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