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Medical Doctor
10-15 minutes

Inpatient Admission H&P

The Hospitalist H&P template by s10.ai is an all-encompassing resource crafted for physicians to meticulously document a patient's history and physical examination during hospital admission. This template excels in capturing comprehensive details about the patient's chief complaint, history of present illness, past medical history, and review of systems. It features dedicated sections for physical exam findings, lab and imaging results, and a detailed assessment and care plan. Perfectly suited for hospitalists handling intricate cases that demand extensive documentation, this template ensures that all pertinent clinical information is efficiently recorded. Optimized for integration with AI medical scribe software like s10.ai, it empowers clinicians to enhance their documentation process and improve patient care outcomes.

1,693 uses
4.2/5.0
A
Alexander Thompson
Template Structure

Organized sections for comprehensive clinical documentation

Chief Concern: [Specific inquiry or reason for the consultation]
History of Present Illness: [Indicate the patient's age and pertinent past medical history. Comprehensive history of the current illness in narrative form. This should encompass onset, triggering factors, quality, radiations, severity, and time course. (only include if applicable)]
[Comprehensive history of investigations and findings conducted in the emergency department or transferring facility. This should include medications given in the emergency department. Also include reason for admission to the Hospitalist team. (only include if applicable, narrative)]
Previous Medical History: [Pertinent past medical history (only include if applicable)]
Home Medications: [List of current medications with dosages (only include if applicable)]
Allergies: [List of known allergies (only include if applicable)]
Social History: [Pertinent social history including tobacco, alcohol, drug use, marital status, living situation, pets, hobbies (only include if applicable)]
Family History: [Pertinent family medical history (only include if applicable)]
Review of Systems:
Constitutional symptoms: [Symptoms like Weight change, Fever, Chills, Night sweats, Fatigue, Malaise (only include if applicable)]
Eyes: [Symptoms like Eye pain, Swelling, Redness, Foreign body sensation, Discharge, Vision changes (only include if applicable)]
Ears, Nose, Mouth, Throat: [Symptoms like Hearing changes, Ear pain, Nasal congestion, Sinus pain, Hoarseness, Sore throat, Rhinorrhea, Swallowing difficulty (only include if applicable)]
Cardiovascular: [Symptoms like Chest pain, Shortness of breath (SOB), Paroxysmal nocturnal dyspnea (PND), Dyspnea on exertion, Orthopnea, Claudication, Edema, Palpitations (only include if applicable)]
Respiratory: [Symptoms like Cough, Sputum production, Wheezing, Smoke exposure, Dyspnea (only include if applicable)]
Gastrointestinal: [Symptoms like Nausea, Vomiting, Diarrhea, Constipation, Abdominal pain, Heartburn, Anorexia, Dysphagia, Hematochezia, Melena, Flatulence, Jaundice (only include if applicable)]
Genitourinary: [Symptoms like Dysmenorrhea, Dysfunctional uterine bleeding (DUB), Dyspareunia, Dysuria, Urinary frequency, Hematuria, Urinary incontinence, Urgency, Flank pain, Changes in urinary flow, Hesitancy (only include if applicable)]
Musculoskeletal: [Symptoms like Arthralgias, Myalgias, Joint swelling, Joint stiffness, Back pain, Neck pain, Injury history (only include if applicable)]
Integumentary (Skin): [Symptoms like Skin lesions, Pruritis, Hair changes, Breast/skin changes, Nipple discharge (only include if applicable)]
Neurological: [Symptoms like Weakness, Numbness, Paresthesias, Loss of consciousness, Syncope, Dizziness, Headache, Coordination changes, Recent falls (only include if applicable)]
Psychiatric: [Symptoms like Anxiety/Panic, Depression, Insomnia, Personality changes, Delusions, Rumination, Suicidal ideation/Homicidal ideation/Auditory hallucinations/Visual hallucinations, Social issues, Memory changes, Violence/Abuse history, Eating concerns (only include if applicable)]
Endocrine: [Symptoms like Polyuria, Polydipsia, Temperature intolerance (only include if applicable)]
Hematologic/Lymphatic: [Symptoms like Bruising, Bleeding, Transfusion history, Lymphadenopathy (only include if applicable)]
Allergic/Immunologic: [Symptoms like Allergic reactions, Auto-immune disorders (only include if applicable)]
Physical Examination:
[Findings from vitals (only include if applicable)]
[Findings from physical examinations etc (only include if applicable)]
Laboratory Results:
Results of [pertinent investigations e.g., bloods, bacteria culture (only include if applicable)]
Imaging Results:
[Results of pertinent imaging e.g., x-rays, CT scans, ultrasound, Echocardiography, MRI (only include if applicable)]
Assessment/Plan:
[1. Issue, problem or request 1 (issue, request or condition name only from clinical context problem list)]
[Impression, likely diagnosis for Issue 1 (condition name only)]
[Differential diagnosis for Issue 1 (only if applicable)]
[Investigations planned for Issue 1 (only if applicable)]
[Treatment planned for Issue 1 (only if applicable)]
[Relevant referrals for Issue 1 (only if applicable)]
[2. Issue, problem or request 2 (issue, request or condition name only from clinical context problem list)]
[Impression, likely diagnosis for Issue 2 (condition name only)]
[Differential diagnosis for Issue 2 (only if applicable]
[Investigations planned for Issue 2 (only if applicable)]
[Treatment planned for Issue 2 (only if applicable)]
[Relevant referrals for Issue 2 (only if applicable)]
[3. Issue, problem or request 3, 4, 5 etc (issue, request or condition name only from clinical context problem list)]
[Impression, likely diagnosis for Issue 3, 4, 5 etc (condition name only)]
[Differential diagnosis for Issue 3, 4, 5 etc (only if applicable)]
[Investigations planned for Issue 3, 4, 5 etc (only if applicable)]
[Treatment planned for Issue 3, 4, 5 etc (only if applicable)]
[Relevant referrals for Issue 3, 4, 5 etc (only if applicable)]
Two Midnight Documentation
The patient's stay is expected to extend beyond 2 midnights in the hospital due to the severity of illness.
Time Spent
[Mention total time spent]
Sample Clinical Note

Example of completed documentation using this template

Chief Complaint: Intense abdominal pain and vomiting
History of Presenting Illness: A 45-year-old male with a background of hypertension and type 2 diabetes arrived with a sudden onset of intense abdominal pain extending to the back, along with nausea and vomiting. Symptoms started 12 hours before admission. The patient notes no relieving factors and describes the pain as constant and severe.
Detailed history of investigations and findings performed in the emergency department or transferring facility: The patient received IV fluids and antiemetics in the emergency department. A CT scan indicated signs of acute pancreatitis. The patient was admitted to the Hospitalist team for further care.
Past Medical History: Hypertension, Type 2 Diabetes
Home Medications: Lisinopril 10 mg daily, Metformin 500 mg twice daily
Allergies: No known drug allergies
Social History: The patient does not smoke, drinks alcohol occasionally, is married, and resides with his spouse and two children.
Family History: Father had coronary artery disease.
Review of Systems:
Constitutional symptoms: Reports fatigue and malaise
Eyes: No symptoms
Ears, Nose, Mouth, Throat: No symptoms
Cardiovascular: No chest pain or palpitations
Respiratory: No cough or dyspnea
Gastrointestinal: Reports nausea, vomiting, and abdominal pain
Genitourinary: No symptoms
Musculoskeletal: No symptoms
Integumentary (Skin): No symptoms
Neurological: No symptoms
Psychiatric: No symptoms
Endocrine: No symptoms
Hematologic/Lymphatic: No symptoms
Allergic/Immunologic: No symptoms
Physical Exam:
Vitals: Blood pressure 140/90 mmHg, Heart rate 95 bpm, Temperature 37.5°C
Abdominal examination: Tenderness in the epigastric area, guarding present
Lab Results:
Elevated serum amylase and lipase levels
Imaging Results:
CT scan of the abdomen showed pancreatic inflammation consistent with acute pancreatitis
Assessment/Plan:
1. Acute Pancreatitis
   - Impression: Acute pancreatitis
   - Differential diagnosis: Gallstone pancreatitis, Alcohol-induced pancreatitis
   - Investigations planned: Liver function tests, Ultrasound of the abdomen
   - Treatment planned: NPO (nil per os), IV fluids, Pain management with analgesics
   - Relevant referrals: Gastroenterology consult
Two Midnight Documentation
The patient's stay is expected to exceed two midnights in the hospital due to the severity of illness.
Time Spent
Total time spent: 1 hour
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template is designed to streamline the documentation process for healthcare professionals, ensuring accurate and efficient recording of patient encounters. With sections dedicated to Chief Complaint, History of Presenting Illness, Past Medical History, and Review of Systems, this template facilitates thorough patient assessments. It includes detailed fields for Physical Exam findings, Lab and Imaging Results, and a structured Assessment/Plan to guide clinical decision-making. The template also incorporates Two Midnight Documentation and Time Spent, crucial for compliance and billing purposes. By adopting this template, clinicians can enhance patient care, improve workflow efficiency, and ensure adherence to clinical documentation standards. Explore this template to optimize your clinical practice today.
Frequently Asked Questions

Common questions about this template and its usage

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Inpatient Admission H&P