Admission note

Header

• Date and time · your name and grade · ward
• Patient identifiers · age · source of history (patient or collateral)

Presenting complaint

• In the patient’s own words, with duration

History of presenting complaint

• Onset and timeline · character, course, associated symptoms
• Relevant positives and negatives
• What has already been done (ED, GP, pre-hospital)

Past medical & surgical history

• Each condition: diagnosis and since when · who follows it up · compliant or not · medication side effects · complications of the disease
• Previous operations

Drugs & allergies

• Regular medications with doses · recent changes · adherence
• Allergy and the reaction it causes, documented clearly

Family & social history

• Relevant family history
• Smoking · alcohol · recreational drugs
• Occupation · baseline function and mobility · home setup · who is at home

Systems review

• Brief screen by system: cardioresp, GI, GU, neuro, MSK

• Observations: HR · BP · RR · SpO₂ (and O₂ delivered) · temperature · NEWS2
• General inspection
• By system: CVS · respiratory · abdomen · neurology · targeted to the presentation

• Bedside: ECG · capillary glucose · urinalysis · VBG or ABG · pregnancy test (βhCG) if indicated
• Bloods: FBC, U&E, LFTs, CRP · cultures if febrile · cross-match or reserve as needed
• Imaging: CXR · further imaging as indicated by the presentation

Impression

• A one-line summary, then the most likely diagnosis and key differentials

Problem list

• Number each active problem

Plan, problem by problem

• Investigations · treatment with doses · monitoring · referrals

Summary statement template

[Age]-year-old [gender], known [key background], presenting with [duration] of [main symptoms]. Most likely [working diagnosis]; differentials […].

• VTE risk assessment and prophylaxis decision
• Escalation plan and named senior review
• Estimated discharge date and discharge considerations