Admission Note Template with Examples

Admission Note Template

This admission note template is designed for doctors and other members of a multidisciplinary team (MDT) to efficiently document patient admissions to a healthcare facility. It includes comprehensive headings and prompts to capture patient demographics, insurance information, medical history, and reasons for admission. Here are other features:

• A flexible template suitable for booked or unplanned admissions.
• It can be started by clinical support staff and then handed over to a doctor for completion.
• AI enables information from referral or background documents to auto-populate in the admission note template.

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What is an Admission Note Template?

An admission note template is a clinical document that guides the recording of essential information when a patient is admitted to a hospital or a healthcare facility. It provides a comprehensive snapshot of the patient’s condition, including the reason for admission, medical history, clinical assessment, and a preliminary treatment plan.

Admission notes often include a large amount of information from various sources. As a result, they take a long time to complete and tend to be a cognitively taxing task for clinicians. Using a high-quality admission note template can improve the accuracy and efficiency of admission notes while reducing cognitive load for clinicians. 

In this article, we’ll explore the benefits of admission note templates and common challenges experienced by clinicians. We'll also cover how to write an admission note (with loads of examples) and provide free AI-powered templates to further streamline your workflow. 

Benefits of an Admission Note Template

Any clinician who has worked in a triage or admissions-type role knows admission notes take a long time to complete.

A study tracking time spent on clinical documentation among internal medicine residents found that the average admission note takes 113.3 minutes to write. Therefore, an admission note template that reduces documentation time while maintaining accuracy would be a big win for clinicians, patients, and hospital administrators.

When researchers looked at the impact of implementing an admission note template in a pediatric setting, they found use of a template decreased the average time residents spent on admission notes by a staggering 23% (from 97.9 minutes to 71 minutes). Crucially, attending physicians spent no more time editing and signing notes produced with templates, indicating that quality and accuracy was maintained.

The time-saving benefits of templates can be further enhanced through the use of AI. Clinicians utilizing Heidi’s AI medical scribe consistently report reducing their daily documentation time by up to 50% (or 1-2 hours per day), with these benefits evident across specialties as diverse as primary care, psychiatry, allied health, and veterinary medicine.    

Common Challenges Using Admission Note Templates

Despite their benefits, clinicians may encounter several challenges when using admission note templates. 

Time Pressures

Healthcare providers often face significant time pressures when completing admission notes, especially in emergency departments and during busy periods. In these situations, when decisions must be made quickly and multiple patients are waiting for care, completing an entire structured admission note template can seem particularly onerous.

When faced with this challenge, it’s wise for clinicians to remember two things: 1) Using a template (like an emergency department admission note template) is generally faster than writing a free-form admission note; 2) Fixing an error due to leaving out crucial information takes more time than writing the note thoroughly the first time.

Balancing Detail with Relevance

Admission note templates in generalized practice settings are intentionally broad. For example, a standard hospital admission note template might cover the entire range of physical, mental, and social problems a patient could present to hospital with. Therefore, it’s essential to rationalize the information that’s entered into an admission note when using a template.

Ideal practice varies on a case-by-case basis. However, it’s usually acceptable to make a brief note (such as “not assessed”) in sections that aren’t relevant in an admission note template and move on to the next topic. This makes the documentation process more efficient and keeps documentation concise and easy to read.    

Maintaining Clinical Reasoning

An overly structured admission note template sometimes reduces documentation to a series of checkboxes, potentially diminishing the natural flow that facilitates clinical reasoning. This rigid approach may negatively impact care planning and reduce the admission note’s usefulness for other clinicians.

If you struggle with clinical reasoning while using an admission note template, try writing your thoughts in narrative form using any free-text fields or even writing an accompanying SOAP note or progress note. Narrative notes can help you to engage in (and document) more abstract reasoning while still gaining the efficiency benefits of a structured template.

Customization Limitations

Standard admission note templates don’t always cater to the personal preferences of a clinician or the unique needs of certain patient populations. If a template can’t be modified, the clinician may wish to write an accompanying treatment plan, medical history summary, mental state examination, or other type of clinical note to add depth to the template. It’s also possible to find customizable admission notes templates where this information can easily be incorporated into the structure.

Heidi’s Template Community contains dozens of field-tested, specialty-appropriate templates created by clinicians of all backgrounds. If you can’t find an admission note template that perfectly matches your needs in the Community, you can easily make edits to one that’s close to what you are looking for.

How to Write an Admission Note with Examples

Exact details and formats vary by specialty and organization. However, admission note templates generally follow a similar basic structure.

• Patient information - Relevant demographic details and insurance information 
• Reason for admission - The reason the patient has presented or been referred to hospital
• History of presenting illness - A brief overview of the primary problem causing the patient to seek care
• Past medical history - Overview of the patient’s prior medical history
• Current medications - A full list of the patient’s current medications
• Social and family history - Relevant information about the patient’s social situation
• Physical examination & investigations - Detailed record of assessments, investigations, and any interventions undertaken during admission 
• Assessment - The clinician’s assessment of the patient’s presenting problem
• Plan - Proposed plan of action (eg., observations in the emergency room, admission to hospital, or discharge)

To create an admission note, the clinician fills in relevant details under each heading while assessing the patient. Below are some examples of how this general structure might be applied across admission notes in different practice settings.

Hospital Admission Note Template

This example is a shortened version of what may be documented with a hospital admission note template for a patient presenting with chest pain.

Patient information - 67-year-old male presenting via ambulance at 20:17. 

Reason for admission - Chest pain and dyspnoea for 3 hours (from around 17:00 tonight)

History of presenting illness - Patient reports sudden onset of “pressure like” chest pain soon after finishing dinner. Describes pain as 8/10 in intensity and radiating to left arm. Associated shortness of breath, “like I can’t catch my breath, doc.” Symptoms began while watching television - not provoked by exertion. No relief with rest.

Past medical history - Hypertension, T2DM (managed with oral hypoglycemics), hyperlipidemia, previous MI in 2018.

Current medications - Metformin 500 mg BID, lisinopril 20 mg daily, atorvastatin 40 mg daily, metoprolol 25 mg BID. 

Social and family history - Former smoker (30-pack a year history, quit after MI). Retired construction worker living at home with wife. Alcohol use <10 standard drinks per week. No illicit drug use. 

Physical examination 

Vital Signs: BP 168/96, HR 92, RR 22, Temp 98.6°F, SpO2 94% on room air.

General: Anxious, moderate distress, diaphoretic.

HEENT: Normocephalic, atraumatic, pupils equal and reactive, no JVD.

Cardiovascular: Regular rhythm, tachycardic, S1/S2 normal, no murmurs/rubs/gallops.

Respiratory: Increased work of breathing, no wheezes or crackles.

Abdominal: Soft, non-tender, non-distended, normal bowel sounds.

Extremities: No edema, pulses 2+ bilaterally.

Neurological: Alert and oriented x3, normal strength all extremities.

Investigations - 

ECG: 1mm ST-segment elevation in leads V2-V4

Initial Troponin I: 0.32 ng/mL (elevated)

BNP: 420 pg/mL (elevated)

CBC: WBC 9.2, Hgb 13.8, Plt 245

BMP: Na 138, K 4.0, Cl 102, CO2 24, BUN 18, Cr 1.1, Glucose 156

Chest X-ray: No acute cardiopulmonary process

Assessment
Acute coronary syndrome, likely STEMI, anterior wall

Hypertension, poorly controlled

Plan

• Cardiology consultation for urgent cardiac catheterization
• Clopidogrel 600mg loading dose
• Heparin drip initiated per ACS protocol
• Monitor cardiac enzymes q6h
• Telemetry monitoring
• Oxygen therapy to maintain SpO2 >94%
• Continue home medications except metformin (hold due to potential contrast use)
• Blood glucose monitoring q6h with sliding scale insulin coverage

ICU Admission Note Template

Below is an example note written following an ICU admission note template for a patient admitted post motor vehicle accident.

Patient information - 23-year-old female admitted to ICU via ED at 07:45 

Reason for admission - Respiratory distress and altered mental state following MVA

History of presenting illness - Patient was the restrained driver in a high-speed motor vehicle collision at approx. 03:30. Initial GCS at scene was 13. In the emergency department patient became progressively more dyspneic and confused, with decreasing oxygen saturation despite supplemental O2. CT chest revealed bilateral pulmonary contusions and right-sided pneumothorax. Intubated for respiratory failure and hypoxia prior to ICU transfer.

Past medical history - Nil recorded and no medications. Still chasing up NOK to clarify.  

Social and family history - Unknown. 

Physical examination 

Vital Signs: BP 92/58, HR 122, RR 18 (ventilated), Temp 38.2°C, SpO2 94% on FiO2 60%

Neurological: Intubated and sedated on propofol drip. RASS -3. Pupils equal and reactive. Withdraws to pain in all extremities.

HEENT: Facial contusions, endotracheal tube secured at 23cm at teeth, orogastric tube in place.

Cardiovascular: Tachycardic, regular rhythm, no murmurs, weak peripheral pulses, capillary refill >3 seconds.

Respiratory: Mechanically ventilated, bilateral chest tubes in place, decreased breath sounds bilaterally with occasional crackles.

Abdominal: Soft, mild distension, bowel sounds hypoactive.

Skin: Multiple contusions on chest and abdomen, abrasion on right forearm.

Extremities: No obvious deformities, right lower extremity ecchymosis.

Investigations (handover from ED)

ABG: pH 7.28, pCO2 48, pO2 82, HCO3 22, BE -4

CBC: WBC 15.2, Hgb 11.2, Plt 178

BMP: Na 138, K 3.8, Cl 100, CO2 22, BUN 22, Cr 1.4, Glucose 168

Liver function: ALT 220, AST 345, ALP 98, Total bilirubin 1.2

PT/INR: 14.2/1.2, PTT 34

Lactate: 3.8

Troponin: 0.04 (negative)

CT Head: No acute intracranial abnormality

CT C-spine: No fractures or dislocations

CT Chest: Bilateral pulmonary contusions, right pneumothorax (now with chest tube), small left pneumothorax (now with chest tube), non-displaced right 4th-7th rib fractures

CT Abdomen/Pelvis: Grade I liver laceration, no free fluid

Ventilator settings

Mode: Volume-controlled

Tidal Volume: 450mL (6mL/kg IBW)

PEEP: 8 cmH2O

FiO2: 60%

RR: 18

Current Blood Gas Values: As above

Assessment

‍Traumatic pneumothoraces with bilateral chest tubes

Pulmonary contusions with hypoxemic respiratory failure

Grade I liver laceration

Multiple rib fractures

Potential traumatic brain injury

Plan

• Ventilator management: Continue current settings
• Goal SpO2 >92%
• Hemodynamic management: Fluid resuscitation with balanced crystalloids. Vasopressors if needed to maintain MAP >65. Serial lactate measurements
• Sedation: Propofol drip, titrate to RASS -2 to 0
• Pulmonary: Continue chest tube management
• Pulmonary toilet q4h
• Liver laceration: Serial hemoglobin checks q6h. Surgical consultation for monitoring
• Nutrition: Enteral nutrition via orogastric tube
• Consults: Trauma surgery, pulmonary medicine, neurology
• Monitoring: Continuous cardiac monitoring, hourly neurological checks, serial ABGs

Hospice Admission Note Template

This note demonstrates how a hospice admission note template could be used to document admission to a home hospice service. Compared to the hospital-based examples above, this template includes more extensive prompts for social, family, and spiritual needs.

Patient information - 82-year-old female visited at home for admission to hospice service. 

Referral source - Oncology department at Memorial Hospital

Medical history - Stage IV pancreatic adenocarcinoma diagnosed 8 months ago. Initially treated with FOLFIRINOX for 4 cycles with disease progression. Subsequent gemcitabine/nab-paclitaxel discontinued after 2 cycles due to intolerance and further disease progression. Recent hospitalization 2 weeks ago for pain control. Patient and family elected to focus on comfort care, with oncology supporting transition to hospice services. Primary symptoms include abdominal pain, nausea, early satiety, progressive weakness, and fatigue.

Current medications - Morphine sulfate oral solution 20mg/mL, 0.5mL q4h PRN for breakthrough pain, morphine sulfate ER 30mg PO BID, ondansetron 4mg PO q8h PRN nausea, dexamethasone 4mg PO daily, senna-docusate 1 tablet BID. 

Social history - Widow (husband died 5 years ago), lives with daughter and son-in-law. Three adult children, all involved in care. Retired school teacher. No history of tobacco or alcohol use.

Spiritual needs - Catholic, wishes for priest to visit. Find comfort in prayer ad family presence.

Family situation - Daughter is primary caregiver - appears knowledgeable but anxious about medication administration. Family is unified in supporting hospice care and honoring patient’s wish to remain at home.

Functional assessment  

Karnofsky Performance Status: 40%

PPS: 40% (mainly in bed, requires considerable assistance)

ADLs: Requires assistance with bathing, dressing, and transfers; continent but needs assistance to bathroom

Mobility: Ambulates with walker for short distances with assistance, primarily bed-to-chair

Nutritional status: Poor, oral intake approximately 25% of normal

Prognosis - Estimated 4 - 6 weeks based on disease progression and functional decline.Acute coronary syndrome, likely STEMI, anterior wall

Hypertension, poorly controlled.

Plan

• Pain management: Continue current morphine regimen, titrate as needed for comfort
• Symptom management: Antiemetics for nausea. Continued dexamethasone for inflammation and appetite. Laxative regimen for opioid-induced constipation.
• Support: RN visits 3x weekly initially, more frequently as needed. Social worker visit within 3 days to provide additional family support. Chaplain visit per patient request. Home health aide 3x weekly for personal care assistance
• Equipment: Hospital bed, Bedside commode
• Advance care planning: DNR order completed and on file

Sample Admission Notes Template PDF

No matter how good your template is, admission notes still take significant time to complete. Furthermore, clinicians often find it difficult to balance their attention between completing documentation and engaging with the patient. The solution to these challenges is to use an AI-enabled template with a scribe like Heidi.

Effortlessly Write Admission Notes with Heidi

Heidi’s AI medical scribe does all the heavy lifting around writing admission notes for you. Just press transcribe, conduct your assessment as usual, and Heidi processes everything said during the assessment (plus any background information you upload). When finished, simply choose your template and Heidi generates a perfectly structured admission note. 

Benefits of using Heidi’s AI medical scribe include:

• Better documentation efficiency - Heidi significantly reduces the time it takes to write admission notes. 
• Enhanced quality of care - With Heidi looking after your notes, 100% of your attention goes to the patient you’re assessing or treating. 
• Improved clinician well-being - By reducing documentation time, clinicians can achieve a better work-life balance.

Heidi is wrapped in world-class security standards that meet or exceed regional healthcare data handling regulations across the globe (eg., HIPAA, GDPR, PIPEDA). Used for 1+ million patient consults per week, the tool allows clinicians to work more effectively and focus more on patient care - reducing the risk of burnout. 

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Free Admission Note Templates

ED Admission Note Template

This template is designed for emergency medicine clinicians to document critical patient information during an admission. A comprehensive ED admission note template, it includes sections for history of presenting illness, management en route, past medical history, medications, allergies, social history, management in ED, and the plan for care.

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Medical Admission Note Template

This generic medical admission note template is suitable for a variety of settings. Using a concise structure, the template captures a patient’s personal details, insurance information, and medical history, ensuring a smooth transition from referring facilities to hospital care.

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Psychiatric Admission Note Template

This inpatient intake tool serves as an effective psychiatric admission note template. It facilitates the recording of psychiatric history, current medications, substance use, social and family history, and mental status examination. It also includes sections for safety assessments and treatment planning, ensuring a holistic approach to patient care.

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Admission Note Template FAQs

What are the admission notes for a patient?

Admission notes can include any clinical documents completed during a patient’s admission to hospital. We’ve covered the formal admission note in this article, but other documents completed at admission may include a patient intake form, medical consent form, history of present illness (HPI), and nursing notes.

What are the basic admission note templates?

Basic admission note templates usually cover the standard sections of an admission note without any customized headings for a specific practice setting. These might be suitable for general medical settings. However, specialized practice areas (like psychiatry or obstetrics) usually require a purpose-built template. 

How do I create my own admission note template?

Creating your own admission note template in Heidi is easy. Just use our template editor to adapt an existing admission template from our community or build your own from scratch. Alternatively, you can give Heidi a reference admission note and ask her to turn it into a template.