presents

The Admit Note

The admit note is the first note written on a patient when they are admitted to the hosptial. This is not to be
confused with the ER note, which in many places is about as good as a one legged man kicking a door in. A good
habit to get into is to write long a thorough admit note so you can reference it later on. Remember the first law??
TRUST NO ONE. Use your own notes if you want to remember something. This also applies to consult services (ie
Cardiology, GI, Pulmonary). The first note you write as a consultant should be admit note style, just more focused
on one particular system. All notes will follow the basic SOAP format. Keep in mind the examples given are
guidelines and not the definitive method of note writing. There are many variations on this that are all fine and
dandy as long as the important information is there. I'll define most of the abbreviations for clarity even if they
seem obvious. Medical abbreviations have taken on a life of their own much like l33t. Love them or hate them its
a big part of the language we speak so I'll try to expose you guys to some here. Now on with the show

The Subjective:
This is the subjective section. Basically anything that can come out of the patients mouth other than vomit
should go here. Here is a sample so you get a feel how things are organized on the page:

The first couple things are just logistics. Date and time every note, things happen very quickly in a hospital
and a patient you see at 7:00 can be dead at 9:00 and its going to look real silly if your note says the patient is
just fine unless you can prove you saw him before he crashed. Also always write what service you are on at the
time. People will be looking for what the internist has to say or what cardiology's recommendation is, so always
identify yourself. The same goes for orders when you get there, always write what service they are coming from.
The actual note starts off with the chief complaint (CC). Now, this technically should be in the patients own
words surrounded by quotation marks but you will quickly find out that this is frequently not the case. Please, do
not let me discourage you from doing this the proper way but you'll find that the CC often turns into the "reason
for admission" or "reason for consult". This is more or less because you are not the first person seeing this
patient. They have already been screened by the ER and admitted for one reason or another. The reason for
admission in this particular example is Shortness of Breath (SOB)
Next on the list would be the History of Present Illness (HPI). Nothing special here just make sure its thorough
and you cover all the bases. Always start the same way as the example giving the age, sex, and pertinent history
(Hx) of the patient. This is redundant but it will help you later when you are presenting the patient. In lieu of a
regular ROS, I usually ask more focused questions relating to the problem and combine it with the associated
symptoms. These people are not here for a physical. Now, some insurance companies require a ROS and get
antsy in the pantsy when its not clearly labeled for them, so do what you (or your attending) need to do. The rest
you should know how to do so I won't waste time going through the whole thing. I will say that depending on the
time that has elapsed between the patient presenting to the hospital and you seeing them you should fill in the
blanks if anything pertinent happened... like say the patient came in for vomiting but after he was admitted
slipped and hit his head... you may want to mention it. And again for the sake of clarity here are the abbreviations
I used: Coronary Artery Disease (CAD), Myocardial Infarction (MI), Left Anterior Descending (LAD), Percutaneous
Coronary Intervention (PCI).
After the HPI comes everything else, more specifically the Past Medical History (PMHx), Past Surgical History
(PSHx), Family History (FHx), Social History and home meds. Notice that I do not have allergies listed. This is
because they are usually written somwhere else on the chart and often times it is written on every page. Feel
free to write it anywhere you wish. No one will ever fault you for writting a patients allergies on any note you
write. Wherever it is make sure you make note of it. I don't think I have to go into what constitutes a PMHx, PSHx
or FHx, except for the fact that dates matter with some events and surgeries. Cardiac caths, MI's, cancer and
subsequent resections are a few that you should always know when it happened. No one is going to care when
the gallbladder came out unless some post surgical complication is suspected, like a small bowel obstruction. For
the social history, especially in elderly patients, make sure you ask if they live alone or with someone or if they
are in an ALF or a similar facility in addition to the usual tobacco/alcohol/illicits questioning. Here are a few more
abbreviations I've used: Gastro Esophageal Reflux Disease (GERD), Congestive Heart Failure (CHF), Hypertension
(HTN).
Now for the meds. You'll notice there are two columns for meds, one next to the social history and one in the
date/time column. The meds listed next to the social histoy are the meds that the patient takes at home. List
them all in the same format almost as if you were writing a prescription (drug name - strength - route -
frequency). You'll notice I used "daily" instead of "qd". Hospitals are cracking down on some abbreviations and
that happens to be one of them. You need to get used to writing "daily". The other meds column is listing what
the patient is on in the hospital. You will list this on your daily progress notes which is covered in the next
section. Everything the patient is taking, every IV, every breathing treatment, will be written here. If the patient is
taking an antibiotic you must make a note of how many days it has been given. The first day the antibiotic is
given is day one. This seems obvious but I only mention this because you will learn later surgical patients are
post operative day (POD) zero the day of the surgery. Also if the patient was started on a steroid make note of
how many days it has been given. That's pretty much it for the medication section.

The Objective:
This is the objective section. All of your exam findings, information the nurses have gathered, labs, radiology,
and anything else you can think of goes here. Here's a little sample:

The first thing here is always the vital signs. You'll notice that I have more then just one result written. You
should make it a habit to write the 24hr range of vital signs down. Think about it. Who cares if the patient's heart
rate is 80 now when it was 150 this morning. For temperature you can just write the highest value (or lowest if
less than 96.8). You should also write the patients oxygen saturation (taken via pulse/ox) if the information is
available as well as the patients ins and outs (I/O) for the last 24hrs. This is essentially all the fluids both IV and
PO that went "in", and every fluid that came "out" including urine, blood, and gastric juices. These are extremely
important but at the moment its beyond the scope of the current discussion. For now just remember to write
them down and be sure to say how much came out of where (ie urine in the foley versus blood from a drain).
Next is your physical exam. You guys should already have a general idea of what to do. Just make sure to
tailor it to the patient's presenting complaint. As I said before, this first exam should be your most thorough
exam. Every patient regardless of complaint should at the very least have a General, HEENT, Heart, Lungs,
Abdomen, and extremeties exam done. You should probably add a quick neuro exam to that list but honestly
when people come in presenting like the above patient its usually farthest from your mind and usually gets
skipped. Now, don't let me steer you away from it. No one will fault you (for the most part) for over examining a
patient as long as you pick up the key findings. Also make sure to document your negative findings. If you don't
write it, it's assumed it was never done. There are alot of variations of how to write the physical exam, for
example some people like to break up eyes and ears from the HEENT section or place a finding like JVD under
Neck instead of Heart. It really doesn't make any difference, do it which ever way you like. Just don't do anything
ridiculous like putting a heart exam under extremeties. People like to go crazy here with the abbreviations so
here are the ones that I've used: No Apparent Distress (NAD), Awake Alert and Oriented times three (AAOx3),
Atraumatic Normocephalic (AT/NC), Pupils Equal Round and Reactive to Light and Accomodation (PERRLA),
Regular Rate and Rhythm (RRR), Jugular Venous Distention (JVD), Clear To Ascultation (CTA), Bilaterally (B/L),
Bowel Sounds (BS), Clubbing Cyanosis or Edema (c/c/e). Added to this I like to use the zero (circle with a slash) to
denote "no" or "negative", as in "no JVD". Also be aware that many people us "BS" for "Breath Sounds" as well as
"Bowel Sounds" along with some other choice phrases so be wary.
Next come the lab values. For the admit note, since it is the first note, every lab result that you have for the
current admission should be included. Later on when you do your progress notes this will change but that is
covered in the next section. In the example I have included a few figures, some that will probably appear on
every note you will ever write. These are the shorthand presentations for the Complete Blood Count (CBC), Basic
Metabolic Panel (BMP), Arterial Blood Gas (ABG), and coagulation studies. They are by no means all inclusive of
the information these studies contain but its more or less an industry standard at this point. Lets start with your
bread and butter, the CBC and BMP. Here is what they include: White Blood Cells (Wbc), Hemoglobin (Hgb),
Hematocrit (Hct), Platelets (Plts), Sodium (Na), Potassium (K), Chloride (Cl), ***Carbon Dioxide (CO2)***, Blood
Urea Nitrogen (BUN), Creatinine (Cr), and Glucose. You'll notice that I have a few asterisks next to the CO2. That's
because it really isn't CO2, but every lab report you read will say "CO2". This value is actually the measured
bicarbonate which is used to approximate the CO2. Just keep this in mind. Also just as a side note when you write
these shorthand figures just write the vaules, not the abbreviations. There are other values on the CBC and BMP
that you will want to include such as the Mean Corpuscular Volume (MCV) or the Calcium (Ca) level. Unfortunately
there is not a widely accepted shorthand for these so you just have to write them the old fashioned way (ie MCV
= 90 and so forth). Now we move to the ABG. Here is what it includes: pH/partial pressure CO2/partial pressure
O2/bicarb/O2 saturation. Make sure you note whether or not this was taken on room air (RA) or on some level of
oxygen support. Ironically, here the bicarb is in fact not bicarb but a calculated value which is more or less
useless. If you need the bicarb get it from the BMP. I've seen a variation on this where the base excess is inserted
between the bicarb and O2 saturation. It's fairly obvious since it will (hopefully) be a very low value, usually single
digit. Add it if you like. The last shorthand is for the coags and I've seen it written upside down as well as this
way. Most of the time you should know what is what no matter how it is written. This shorthand includes the
Prothrombin Time (PT), Partial Thromboplastin Time (PTT) and International Normalized Ratio (INR). There is one
other crazy shorthand I've seen for LFTs but I rarely see it, no one knows it, and you probably shouldn't use it. All
of the other labs you need to write as is. Some people will argue that you only have to write the abnormal labs
while others say you have to write them all. I'll leave that decision up to you but at the very least you should
know what labs were done and whether they were abnormal or not even if you don't write it. In addition to the
labs you should also write down the finger stick glucose readings for the past 24hrs if your patient is receiving
them. I like to write these in the date/time column under the hospital meds. Write them in order and make a note
of the time each on was taken.
Under the labs, if applicable, you should comment on the EKG and telemetry. For the EKG do not write down
what the machine spits out at the top since it is frequently wrong. You'll have to use your skill and interpret it for
yourself. If it has already been read by cardiology feel free to use their interpretation, but you need to learn to do
it yourself. Remember... TRUST NO ONE! When commenting on telemetry you need to look at the strips that have
been recorded, not just what rhythm the patient is in right now. Make sure you do this on EVERY patient that has
telemtery, not just the cardiac cases. If it's there you may as well look at it. Also, DO NOT write on EKGs, they are
sacred. If you must doodle, make a copy and draw whatever you like on there.
The final thing you should write in the objective section is a few notes on radiology. Write down the results of
whatever scans the patient underwent. Feel free to paraphrase the radiologists report, but don't be afraid to write
it word for word if it's important, confusing, vague, or all of the above. I include pathology reports here as well.
Sometimes it will be appropriate to make a note of an old pathology report, or echocardiogram from a previous
admission. Just be sure to include the date to distinguish it from what has been done on the current admission.

The Assement and Plan:

At last we have reached the finale of the note and by far the most important part: the assesment and plan.
Your entire note exists more or less just for this section. You actually have to think here and come up with what
you think is wrong and the treatment plans you want to follow. This should be written in a way so that others can
read it and have a good idea of what is going on with the patient. Here is a little sample:

You've been previously taught to write the assesment (some call it the impression) and the plan seperately.
In the hosptial this is not the way to go. The whole point of this section is to identify the problems the patient is
having and then address what is going to be done about it. Most people feel that a combined A and P is a better
way to convey the information than two seperate lists. You can argue that you'll just have the numbers correlate
with each other to achieve the same goal but it will probably get confusing and waste space so just combine
them. Some people like to start this section off with one line echoing the first line of the HPI (ie age sex Hx, CC),
which is redundant on the admit note but can be useful when used on subsequent progress notes to remind
everyone how everything started. I generally don't do this since most of this information is going to be in the list
anyway but once again feel free to do it if it makes you happy (or your resident/attending makes you do it).
Again, for the sake of clarity here are some of the abbreviations I used: Pulmonary Embolism (PE), Cardiac
Enzymes (CE).
Logistically, there are two basic formats that you will see, a numbered list and a paragraph form. Both
contain the same information but one is the just organized by problem and the other is a more verbose
explanation. Don't start off using paragraphs, that sort of thing is better fit for consult services. If your attending
wants it he or she will tell or to do it. By default you should just stick to the list format. The list itself has a bunch
variations such as breaking things up by system, but for now i'll just stick to the basic list.
With that out of the way lets get to actually writing the A&P. The first item of the list should ALWAYS be the
reason why the person is in the hospital. The problems should be listed in order of severity. In this case the major
problem is the shortness of breath. Yes, it is fine to write symptoms like this here unless you know for sure why
it's happening (then it's probably time for the patient to go home or have a procedure). After anything you write
here comes the major question... why? You should be asking yourself this question after every thought you have.
Why is he here? Why is he short of breath? Why is he taking that pill? If you don't ask yourself, someone else will,
usually your attending, so be prepared. So when you write "1) SOB" you need to basically write a differential of
what it may be... not a list of 10 things possible but of the most likely suspects. Follow that up with what you are
doing about it, either what tests are ruling it in or out or who you are consulting. If you know what the problem is
then write that it is secondary (or the number 2 with the degree symbol) to whatever condition it may be. In its
simplest form that is the basic idea of what you need to do here. Unfortunately, it's the thought process that is
key here and it's something I can't easily convey in a little paragraph so hopefully you'll be able to cultivate it on
your own during rotations. For the rest of the list you just go problem by problem in order of severity and do the
same thing. Here is where you have to look up at your note and make sure to address any abnormalities. If the
patient has a fever, tachycardia, hypokalemia, leukocytosis, etc., you'd better mention it here as one of your
assesments and say what you think is going on. The last few lines should be the pertinent Hx that needs to be
controlled such as diabetes, HTN, GERD, etc. Some people like to add a line or two to confirm that the patient is
receiving the proper GI and DVT prophylaxis. You can do it if you like, it certainly can't hurt and those are two
things you should always be on top of. Remember to keep in mind people should be able to read this and know
what's going on with the patient, and along these lines you should be able to go back to this the next day and
have everything fresh again in your mind, so make sure you cover all the bases.

And that's it, SOAP notes in a nutshell. Hope this helped get you started on your way to your career of
seemingly endless note writing. You can download the entire sample note in PDF format here. I will update this
page soon as this is the first edition of it so stay tuned.

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