Medical Review/Admission Note

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

# MEDICAL REVIEW - [admitting doctor]

[patient age and sex] | [Admitting team/service] 

Referred as: [Referral reason]

## BACKGROUND
(hyphenated list, append with "bg::" before entry and enclose in parentheses)
- [previous diagnoses with years first recognised where known, eg Non-Ischaemic Cardiomyopathy, 2021](keep diagnosis brief to a few words at most)  
              - [brief details of complications and previous investigations](if stable disease does not need additional details) 
              - [any specialists patient is known to for this diagnosis] 


### Family History:
(hyphenated list)
[relevant medical history, if no history state "no relevant family medical history"]

### Substances:

(hyphenated list)
[smoking status, in non-smoker to state if previous smoker and how many years not smoking, if never smoked to state "lifelong non-smoker"]  
[other substances consumed with legal or illicit]  

## CFS: [Rockwood clinical frailty score](only include if patient is over 65 years of age, otherwise omit CFS entirely) 

### Social/Supports: 

[current functional status and home situation eg. living alone independent, living with in-home supports, 4WW mobility]  

## MEDICATIONS

(do not use brand names)
[current medications taken with dose and frequency eg. Metformin XR 500 mg BD]  
[whether patient manages medications themselves directly from packets, whether they are helped by family, or have a webster pack]  
[statement if patient misses medications frequently or cannot recall medication schedule, eg. thinks misses medications few times per week, takes all medications in the morning whether not prescribed BD or daily]  

## HISTORY OF PRESENTING COMPLAINT

[primary symptoms that brought patient to hospital with quoted descriptions of key symptoms eg. presenting with chest pain since yesterday, described as "punched in chest"]

[any symptoms that patient denies having on questioning]  

[and additional history on systems review not fitting with primary complaint eg. experiencing on-off nausea for months, had leg rash a few weeks ago that now resolved]

(only include if discussed at time of review) 
[advanced care planning discussion and discussions around resuscitative management] 

## OBSERVATIONS

[current vital signs and any trends, eg. BP improving, tachycardia improving, and state if any fevers recently]  

(do not include if particular system has not been examined in review)
[respiratory examination findings] 
[cardiovascular examinations findings] 
[fluid status, eg. euvolaemic, hypovolaemic] 
[abdominal exam findings] 
[neurological exam findings]  

[fluid balance, weight, whether drains or catheters are in situ and functioning]  

## INVESTIGATIONS

[current bloods test results such as biochemistry, haematinics, etc, troponin results, d-dimers, blood gases, and blood cultures should be given an individual line, eg Na 136 K 4.6 Mg 0.73]  

[current orifice results such as stool samples, urine samples, nasal swabs, etc, eg. Urine MCS <10/<10/<10]  

[imaging findings in this specific admission and a comment on if these findings have been noted previously, eg. CXR: mildy congested appearance, mild right pleural effusion, noted plerual plaques similar to previous CXR]  

[description of ECG, eg, ECG: sinus with 1:1 conduction, normal left axis, narrow QRS, no ischaemic changes, no dynamic changes]  

[any additional testing that is relevant to the presenting complain such as transthoracic echocardiagrams that have been previously performed for a heart failure patient, or spirometry performed in a COPD patient, eg. recent TTE: dilated LV with LVEF 40%, normal valves]  

## IMPRESSION

(enclose each sentence with parentheses and append with "impression::" at start)
[age and sex of patient with their current living situation and functional status, with their current primary diagnosis eg. 60M ordinarily well and independent with ACS]  
[their current clinical status and expected prognosis or trajectory, eg. currently clinically stable and improving]  
[key differentials that still need to be investigated for or ruled out eg. ddx - pulmonary embolism given long travel, pericarditis given pleuritic nature](only include differentials that have been discussed with the patient or that are being investigated as part of the plan) 
[additional complications of the primary diagnosis, eg. complicated by pulmonary oedema, congestive hepatopathy, aki]  
[additional diagnoses that require intervention currently or further investigation eg. hypokalaemia, hyperglycaemia]  

### PLAN

(hyphenated list, enclose each management item that is specific action in parentheses and append with "a::" at the start)
- Admit To: [Admitting team/service]
- [current immediate management actions to be taken eg. bolus fluids, vasopressor supports, urgent antibiotics] 
- [management actions to be taken for the primary diagnosis]
- [management actions to be taken for additions diagnoses and complications]
- VTE prophylaxis [either "as charted" or if it is to be withheld, or not required as the patient is already taking anticoagulant medications]
- [management actions for patient support such as supplemental oxygen to a particular target, hi-flow oxygenation, etc] 
- [whether patient can eat and drink, unless otherwise statement patient can "eat and drink as tolerated]
- [investigations to be further performed]
- [when next planned review is, eg. "review with treating team/service mane"]
- [signs to observe for to notify after hours clinician or request urgent review eg. notify if further chest pain not improving with GTN, notify if fevers] 
- [any additional referrals to specialty teams to be made] 
- [any referrals to allied health teams to be made]


[sign-off with admitting doctor's name, role, and dect number]