Documentation · Ward
Admission note
History
Opening line
- X is a Y-year-old man or woman, known to have …, presented with … for …
- Brought by family or ambulance · collateral history from …
History of presenting complaint
- Onset, timeline, character, course, associated symptoms
- Positives and negatives aimed at the differentials, one short line per system
- Treatment so far, if any: what was given · dose · response
Relevant past history
- Relevant PMH: duration · control · complications · follow-up where relevant
- Previous surgeries with dates and complications
- Risk factors for the differentials, present or absent
Medications and allergies
- Regular meds with doses · recent changes · adherence
- Source of the list: patient · family · pharmacy record · medication packs
- Allergy and reaction
Family and social
- Relevant family history
- Smoking · alcohol · drugs
- Occupation · baseline function and mobility · home setup
- Geriatric: ADLs and iADLs · feeding (oral, NG, PEG) · continence and catheter · aids · carers
Examination
- Vitals: BP · HR · RR · temperature · SpO₂ (room air or O₂) · conscious level
- General: appearance · distress or work of breathing · hydration and perfusion · volume status
- Targeted examination: relevant systems · important negatives
- If indicated: capillary glucose · weight
BMI calculator
Investigations
- Relevant results: document values and important trends
- CBC · U&E · glucose; LFT, CRP, coagulation, VBG, troponin, NT-proBNP if indicated
- ECG and imaging: key findings, one line each
- Pending: anything still outstanding
Impression
- One-line clinical summary
- Most likely diagnosis · key differential
- Numbered problem list: working diagnosis · supporting features · important differential or unresolved question
- Chronic problems only if they require action during this admission
- Anyone else involved: senior, ICU, sub-specialty · name, time, advice
Admission plan (discussed with Dr X)
General
- Admit under unit X, ward Y · isolation if …
- Telemetry or cardiac monitor, for how long
- Oxygen target, titrate
- Escalate and call ICU if: SpO₂ < … · RR > … · SBP < … · HR > … · drop in consciousness
- Diet: regular · diabetic · low salt · renal · soft · NPO except medications from … until …
- Glucose chart: fasting and pre-meal · q6h if NPO · q1h on insulin infusion
- Fluids: IVF type and rate, review in the morning · restrict to X L/day · encourage oral
- Input and output · daily weight · catheter yes or no
- Mobilise with assistance · bed rest · falls precautions
- Elderly or frail: delirium screen · pressure area care · nutrition screen
Investigations
- Labs and imaging by the problem list
- Screening: HbA1c · lipid profile · TFT if needed
- Trend as indicated: troponin · ECG · VBG · lactate · glucose
Quick guide: choosing investigations
- If septic → cultures before antibiotics, lactate and repeat, source imaging → fever
- If AKI → urinalysis, bladder scan, renal ultrasound, daily U&E → acute kidney injury
- If chest pain or dyspnea → trend troponin and ECG, NT-proBNP, echo → chest pain
- If bleeding → group and save, coagulation, repeat hemoglobin → GI bleed
- More examples → progress note examples
Medications
- New drugs: dose · route · frequency · duration · antibiotics with a review date → empiric antibiotics
- DVT prophylaxis: enoxaparin 40 mg SC OD
Quick guide: VTE prophylaxis
- Check platelets and bleeding risk first
- CrCl < 30 → heparin 5000 units SC q8–12h
- Weight < 50 kg or BMI > 40 → adjust dose per local protocol
- Mechanical prophylaxis if anticoagulation is contraindicated
- Indication by risk score → Padua score · MDCalc ↗︎
- PPI only with an indication
Quick guide: PPI indications
- Previous GI bleed or ulcer
- Anticoagulant plus antiplatelet · dual antiplatelet · either one with an NSAID or steroid
- ICU, ventilated or coagulopathic
- Not routine for everyone else
- Glucose: correction scale and threshold · basal insulin in type 1 → hyperglycemia
- PRN: analgesia · antiemetic · laxative with opioids → analgesia
- Medication reconciliation: continue · hold · adjust · reason
Quick guide: what usually changes on admission
- Renal dosing: adjust antibiotics, LMWH, opioids, gabapentinoids, DOACs to CrCl → Cockcroft-Gault · MDCalc ↗︎
- Metformin and SGLT2 inhibitors: hold when NPO, unwell, in AKI or before contrast → acute kidney injury
- Insulin: never omit basal insulin in type 1; adjust to intake → hyperglycemia
- Antihypertensives: hold if hypotensive; ACE inhibitor, ARB and diuretic in AKI
- Anticoagulants: hold before procedures, bridge by indication → coagulation profile
- Steroids: never stop abruptly; sick-day and stress doses → steroids
Close the loop
- Pending results: what · when · what to do if abnormal
- Reassess: when · after what intervention
- Consults: question · advice
- Handover: what needs following → handover
Last clinically reviewed · June 2026 · Last updated · October 2026
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