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Primary Care Physician
10-15 minutes

Standardized Hospital Admission Documentation Template

The s10.ai Generic Hospital Admission Notes template is a vital resource for General Practitioners and healthcare providers, designed to enhance the efficiency of documenting patient admissions. This all-encompassing template meticulously records essential patient data, such as personal information, insurance details, and medical history, facilitating a seamless transition from referring facilities to hospital care. By adopting this template, clinicians can optimize the admission process, minimize errors, and elevate patient care coordination. Perfectly suited for s10.ai, this template guarantees the capture of all critical details necessary for a successful hospital admission.

1,933 uses
4.2/5.0
E
Ethan Caldwell
Template Structure

Organized sections for comprehensive clinical documentation

Hospital Details
Referring Facility: [name of referring facility]
Phone: [contact phone number]
Fax: [fax number]
Contact Person: [name of contact person]
Date of Request: [date of request]
Patient Medical Record Number: [medical record number]
Patient Information
Patient Name: [patient's full name]
Date of Birth: [patient's date of birth]
Gender: [Male/Female]
Social Security Number: [social security number]
Marital Status: [Married/Single/Widowed/Divorced]
Address: [patient’s full address]
Home/Cell Number: [patient’s phone number]
Other Contact Number: [alternate phone number]
Mother’s First Name: [mother’s first name]
Father’s First Name: [father’s first name]
Insurance Information
Insurance Plan: [insurance provider name]
Plan ID/Group Number: [insurance plan ID/group number]
Medicaid CIN Number: [Medicaid CIN number]
Medicare Number: [Medicare number]
Is the Patient on an HMO Plan?: [Yes/No]
Plan Name: [HMO plan name] (Please remind patients to bring their referrals on the date of appointment.)
Admission Details
Referring Physician Name: [name of referring physician]
UPIN Number (for diagnostic services): [UPIN number]
Clinic Referred: [name of clinic]
Diagnosis: [diagnosis]
ICD 9 Code: [ICD 9 code]
Request to Rule Out/Evaluate Patient for: [reason for referral]
Time Frame Physician is Seeking for Appointment: [preferred appointment time frame]
Additional Information: (attach reports/lab results, medications taken/exams done/history etc. pertinent to patient care) [relevant medical history, test results, medications, or other pertinent clinical details]
Patient Appointment Day/Time Preference: [preferred appointment day/time] (Please send completed admission notes back - any incomplete detail will not be accepted)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information to include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
Sample Clinical Note

Example of completed documentation using this template

Hospital Information  
Referring Facility: St. Mary's Hospital  
Phone: 020 7946 0958  
Fax: 020 7946 0959  
Contact Person: Dr. Emily Carter  
Date of request: 1 November 2024  
Patient Medical Record Number: 123456789  
Patient Data  
Patient Name: John Doe  
Date of Birth: 15 March 1980  
Gender: Male  
Social Security Number: 987-65-4321  
Marital Status: Married  
Address: 123 Elm Street, London, SW1A 1AA  
Home/Cell Number: 07123 456789  
Other contact Number: 07123 987654  
Mother’s First Name: Mary  
Father’s First Name: Robert  
Insurance Details  
Insurance Plan: s10.ai  
Plan ID/Group Number: HF123456  
Medicaid CIN Number: AB123456C  
Medicare Number: 1234-567-890  
Is the patient on an HMO plan?: Yes  
Plan name: s10.ai HMO  
Admission Notes  
Referring Physician Name: Dr. Thomas Kelly  
UPIN Number (for diagnostic services): A12345  
Clinic Referred: City Health Clinic  
Diagnosis: Hypertension  
ICD 9 Code: 401.9  
Request to rule out/evaluate patient for: Cardiovascular assessment  
Time frame physician is seeking for appointment: Within 2 weeks  
Additional Information: Patient has a history of high blood pressure and is currently on Lisinopril. Recent lab results show elevated cholesterol levels. No known allergies.  
Patient appointment day/time preference: Monday mornings
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive Hospital Information and Patient Data template is designed to streamline the referral and admission process, ensuring seamless communication between healthcare facilities. By incorporating high-search healthcare keywords, this template facilitates efficient data collection, including critical patient demographics, insurance details, and admission notes. Clinicians can easily document and access essential information such as the referring facility's contact details, patient medical record numbers, and insurance specifics, enhancing the accuracy and speed of patient care coordination. The template also includes fields for diagnosis, ICD 9 codes, and appointment preferences, allowing for precise scheduling and follow-up. By adopting this template, healthcare professionals can improve workflow efficiency, reduce administrative errors, and enhance patient satisfaction. Explore this template to optimize your clinical documentation and ensure a smooth referral process.
Frequently Asked Questions

Common questions about this template and its usage

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Standardized Hospital Admission Documentation | Medical Chart Template