Admission Note

Template-structuur

Dit is de structuur die Notat volgt bij het schrijven van de notitie van het bezoek — u vult deze nooit handmatig in.

<b>Admission Note</b>

[Date and time if mentioned]

<b>Patient Identification:</b> [Patient name, age, gender, with a history of..., presenting with...]

<b>History of Present Illness:</b>
(Begin with the chief complaint and duration. Then provide a chronological, problem-oriented narrative that focuses on the reason for consultation. Group related symptoms into coherent separate paragraphs rather than a single block of text. For each main problem or symptom cluster, explicitly address where available: onset, duration, tempo/progression, location and radiation, quality, severity, aggravating and relieving factors, associated symptoms, and key negatives. Include relevant baseline function, prior episodes, relevant past investigations or imaging, prior treatments and response, and any recent triggers. Comment on relevant risk factors for the presenting problem when available. Summarize functional impact where available.  End with a review of systems related to the presenting problem)

[Paragraph 1]

[Paragraph 2]

[Review of systems in a sentence]

<b>Past Medical History:</b>
(hyphenated list)

<b>Medications:</b>
(hyphenated list)
- [Medication name, dose, route, frequency]
- (e.g., Metformin 500 mg oral BID)

<b>Allergies:</b>
(hyphenated list)
- [eg. No known drug allergies (NKDA)]

<b>Family History:</b>
(hyphenated list)
- [Relative: Condition or pertinent diagnosis]
- (e.g., Mother: breast cancer)

<b>Social History:</b>
(hyphenated list)
- [Tobacco: type, amount, duration, quit date if applicable]
- [Alcohol: type, amount, frequency]
- [Recreational substances: type, amount, frequency]
- [Occupation: current job, exposures]
- [Living situation: who lives with patient, home environment]

<b>Physical Examination:</b>
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [Physical exam findings and/or mental status exam findings] (Format as "System: Exam findings", one system per line. Specify anatomical location if relevant)

<b>Investigations:</b>
(hyphenated list)
- [Investigation results with units] (Only include completed investigations, otherwise leave blank. All planned or ordered investigations should be included under Plan)

<b>Assessment & Plan:</b>
(Do not fabricate the assessment and plan unless mentioned in the source material. Use medical terminology if appropriate.)
[One-sentence patient summary including age, sex, and primary diagnosis]

#) [Assessment as a numbered item if mentioned]
- [Hyphenated list with each corresponding plan item on a new line if mentioned]

#) Best Practices (if mentioned)
- [Code status]
- [Lines and tubes]
- [DVT prophylaxis]
- [Diet]
- [Activity]

(ensure numbers are listed for each issue)