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H&P

HOSPITALIST ADMISSION NOTE
[Your Hospital]

ID: []

Referred by: []

REASON FOR ADMISSION:
[]

HISTORY OF PRESENTING ILLNESS:
[]

GOALS OF CARE:
[]

PAST MEDICAL HISTORY:
[]

PAST SURGICAL HISTORY:
[]

ALLERGIES:
[]

HOME MEDICATIONS:
[]

SOCIAL HISTORY:
[]

IMMUNIZATIONS:
[Up to date]

FAMILY HISTORY:
[None relevant]

EXAMINATION:
Vitals: []

General: [Appears well, no pallor, no jaundice, no peripheral edema, no clubbing, no signs of dehydration, skin is normal]
HEENT: [NAD]
Chest: [clear with GAEB, no adventitious sounds]
CVS: [peripheral pulses are present pulse is regular, JVP is normal, S1 S2 = normal, no murmurs]
Abdomen: [No distension, no tenderness on palpation, no hepatomegaly or splenomegaly clinically, bowel sounds are present, no hernias]
Neurology: [orientated x 3, PEARL, No nystagmus, Finger-nose test is normal, heel to shin test is normal, no gaze palsy, CN I - XII roughly intact, power 5/5 throughout, reflexes are normal, Babinski is negative, no neck stiffness]
Musculo-skeletal: [NAD]

SPECIAL INVESTIGATIONS:
[]

ASSESSMENT & PLAN:
[]

DISPOSITION:
Admit to VJH Hospitalist
VTE: []
Diet: []
MOST: [If you made any changes or had discussions, leave out if captured in above section]
Consults: [PT, OT, TL, SW etc]
EDD: []

Thank you for involving the hospitalist service. This document was created using voice recognition software and as a result might contain some errors. If anything is not clear, please do not hesitate to contact me.

Progress Note

Consult

HOSPITALIST CONSULTATION NOTE
[Insert Hospital]

REFERRED BY: []

ID: []

REASON FOR REFERRAL:
[Reason for referral]

HISTORY OF PRESENTING ILLNESS:
[Provide more information about complaint, focusing on symptoms and events leading up to admission. Also incorporate collateral information]

GOALS OF CARE:
MOST [current MOST status]

PAST MEDICAL HISTORY:
[]

PAST SURGICAL HISTORY:
[]

ALLERGIES:
[]

HOME MEDICATIONS:
[]

SOCIAL HISTORY:
[]

IMMUNIZATIONS:
[]

FAMILY HISTORY:
[None relevant]

EXAMINATION:
Vitals: []

General: [Appears well, no pallor, no jaundice, no peripheral edema, no clubbing, no signs of dehydration, skin is normal]
HEENT: [NAD]
Chest: [clear with GAEB, no adventitious sounds]
CVS: [peripheral pulses are present pulse is regular, JVP is normal, S1 S2 = normal, no murmurs]
Abdomen: [No distension, no tenderness on palpation, no hepatomegaly or splenomegaly clinically, bowel sounds are present, no hernias]
Neurology: [orientated x 3, PEARL, No nystagmus, Finger-nose test is normal, heel to shin test is normal, no gaze palsy, CN I - XII roughly intact, power 5/5 throughout, reflexes are normal, Babinski is negative, no neck stiffness]
Musculo-skeletal: [NAD]

SPECIAL INVESTIGATIONS:
[]

IMPRESSION:
[Generate a problem statement that can be carried over to the progress note. This is a summary of the problems identified.]

ASSESSMENT & PLAN:
1. []

Thank you for involving the hospitalist service. This document was created using voice recognition software and as a result might contain some errors. If anything is not clear, please do not hesitate to contact me.

Discharge

Transfer

HOSPITAL TRANSFER SUMMARY

Date of admission: []
Date of transfer: []
Discharge disposition: []
Accepting physician: []

MOST []

Admission diagnosis:
[Main reason for admission]

Secondary Diagnosis:
[All diagnoses during the admission]

Past Medical History:
[Medical history]

Specialist Consults During Admission:
[Name, date, specialty]

Interventions:
[Angiogram Date: ]
[Biopsy: Date & Site]
[Blood Products: dates]
[Cardioversion: Date ]
[CPR: Date]
[Catheter: Date (removed on )]
[Central Lines: Date (removed on )]
[Chest Tube: Date (removed on )]
[Dialysis: Date ]
[Drains: Date and Site]
[Endoscopy: Date and by whom with findings]
[Feeding Tube: Date (removed on )]
[Mechanical Ventilation/BiPAP, CPAP: Date ]
[NG Fees: Date ]
[Pacemaker: Date ]
[Pleurocentesis: Date & findings]
[Paracentesis: Date & findings]
[Radiation: Date ]
[Chemotherapy: Date ]
[Tracheotomy: Date ]
[TPN: Date ]
[Vac Dressing: Date ]

Operative Interventions:
[]

Pertinent Investigations:
[]

Current Medications:
[]

Social Issues:
[]

Summary:
[]

Thank you for involving the hospitalist service. This note was created with voice recognition software and may contain some errors. If anything is unclear, please do not hesitate to contact me.

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