Admission Note/Consult | MedHubOnline

Admission Note/Consult:

Consultation Note or New Admission Note:

1. Identification (ID): Name, age, gender.

2. Reason for Referral (RFR) or Chief Complaint (CC): Why are you seeing them, how did they present?

3. Relevant Past Medical/Surgical Hx (Specific to CC, e.g. if CC is CHF then include CABG, HTN, Dyslipid hx etc..): Include how conditions are managed and any scores pertaining e.g. CHF include EF, A.fib include CHADS2 score etc.. This helps frame the patient.

4. History of Presenting Illness (HPI):

Establish baseline:
Events leading to presentation:
Location:
Management: what have you taken, how was this managed previously.
Onset:
Precipitating/relieving factors:
Quality:
Radiation:
Severity:
Timing:
Review of Systems:

5. Past Medical History (PMHx): Any other less pertaining medical hx

5. Past Surgical History (PSHx): Like PMHx. Include:

When was the surgery?
Was it scheduled or emergent?
Who performed the surgery and at which hospital?
Were there any complications?
What type of anesthetic was used (general, epidural, spinal, local)

6. Family History: Similar conditions or others that could lead to such complications.

7. Medications: Name, Dose, Route, Frequency, Reason for taking.

8. Allergies: Medication Allergies, What type of reaction?

9. Social History: Occupation, marital status, and substance use.

10. Immunization History

11. Physical Exam, Starting with Vitals. Include any bedside investigations e.g. point of care ultrasound here.

12. Investigations performed so far and their results

13. Assessment: Your Impression, most likely dx and other DDx.

14. Issues & Plan:

Issues list (Consider Bio, Psycho, Social) & investigation & managment for each issue
Disposition, where should they go and whats preventing them from going home?

Discipline-specific Addendum

Psychiatry

a. Identification: Include relationship status, occupation, living situation, and number of dependents, independence with iADLs/ADLs.

b. Included in the HPI:

i. Screen for depression (MSIGECAPS)
ii. Screen for mania (GST PAID)
iii. Screen for anxiety (general anxiety disorder, panic disorder +/- agoraphobia, OCD, PTSD)
iv. Screen for psychosis (hallucinations, delusions, negative symptoms of schizophrenia)

c. Past Psychiatric History

i. What was the diagnosis? When was it made? What treatments has the patient had for this diagnosis (pharmacological, psychological)?
ii. Have there been any hospitalizations for psychiatric illness? If so, when were they and how long?
iii. Is the patient followed by a psychiatrist or other healthcare professional for this diagnosis?
iv. Is there any history of self-harm or suicide attempts? If so, when? How many? How often? What were the circumstances?

d. Forensic History

i. Past criminal activity
ii. Any incarceration?

e. Suicidal and homicidal ideation, plan and intent

f. Mental Status Exam (ABC STAMPLICKER)

i. Appearance
ii. Behaviour
iii. Cooperation
iv. Speech
v. Thought form and content
vi. Affect
vii. Mood
viii. Perception
ix. Level of consciousness
x. Insight and judgement
xi. Cognitive functioning
xii. Knowledge base
xiii. Endings (suicide)
xiv. Reliability

Pediatrics

a. Identification: If age < 10 y/o include:

1. Prenatal maternal details: Mother’s age, gravida, term, live births, outcomes etc (ie. GTPAL)
2. Planned vs. unplanned pregnancy, onset of prenatal care
3. Important details of pregnancy: substances (including medication), sickness, screening
4. Birth history: Spontaneous vs induced, vaginal vs C/S, any complications, bw, apgars
5. Post-Natal: NICU required, resuscitation required, length of hospital stay before discharge

b. History of Presenting Illness:

i. OPQRST + PREVIOUS (ie. Past episodes) and PROGRESSION of presenting symptoms
ii. When was child last well? How did current complaint develop.
iii. Establish child’s baseline and how it has changed in terms of:
- 1. Nutrition (For infant’s include feeding details – Breast vs. formula, supplementation, frequency, and duration)
- 2. Growth and Development (how does he/she compare to siblings/friends)
- 3. Level of Activity (keeps up with friends? Tires easily? Energetic? Quiet?)
- 4. For infants include baseline and current urine output (wet diapers) and BM
- iv. Recent exposure: sick contacts (family, school, care providers), recent travel
- v. General: Activity, Appetite, Attitude/Energy (3 A’s of pediatric illness)
- vi. Infant: are they consolable? Crying all the time?

c. Past Medical History:

i. Ongoing diagnoses
ii. Resolved diagnoses
iii. Infancy History:
- 1. Common problems: jaundice, poor feeding, difficulty breathing, inadequate weight gain
iv. History of Hospitalizations and Surgeries

d. Medications, Immunizations, and Allergies:

i. OTC and prescribed medications
ii. Allergies: if present, check for atopy (eczema, asthma) as well as parental history of atopy
iii. Asthma: smoke, pets, carpets, allergens, family hx of atopy/asthma

e. Family History:

i. Health status of family members, number of siblings, childhood diseases
ii. Consanguinity, genetic pedigree
iii. Relevant family history of disease (include autoimmune history if type 1 DM, asthmatic, etc.)

f. Social History:

i. Who lives at home? Primary caregivers? Parental occupation
ii. Attend daycare?
iii. Stressors: relationships, finances, substance use?
iv. School and friends (if applicable)
v. Healthy Active Living: Exercise, sports, social outlets

G. HEADDSS History (For adolescent, Interview teens alone, and assure confidentiality):

i. Home: who lives there, how do they get along
ii. Education/employment: grade level, attendance, favorite/least favorite courses, employment for $ or ‘experience’?
iii. Activities: what do you do for fun/on weekends? Do you think you have enough friends? What extra-curriculars do you do?
iv. Drugs/Substances: Have you ever tried… x y z; frequency, quantity
v. Dieting: concerned about weight/shape? Ever tried to change it? Binge/purge?
vi. Sexuality: Same sex, opposite sex, both? Ever been sexually active? Number of partners, age, STIS history, protection, pregnancy
vii. Suicide/Depression: MSIGECAPS screen, thoughts of hurting self/others
viii. Safety: seatbelts, bike helmets, guns at home, ever felt unsafe?

H. Developmental Milestones:

Obstetrics & Gynecology

a. Obstetrical history:

i. How many pregnancies? What were the outcomes? You should present this information in the following form: G (gravida = how many pregnancies), T (term = how many babies born after 37 weeks GA), P (preterm = how many babies born between 20 and 37 weeks GA), A (abortions), L (living)
ii. For each pregnancy, you want to know how far along the pregnancy went, gender of the child, birth weight, method of delivery (spontaneous vaginal delivery, assisted vaginal delivery, c-section), and any complications during the pregnancy and the delivery.
iii. It is also important to note how these pregnancies were conceived – natural, intrauterine insemination (IUI), in vitro fertilization (IVF).
iv: Include gestational age and expected delivery date, mothers BMI, blood/rh group, vzv titre, GBS status, urine C&S, diabetes and thyroid status, use of folic acid/prenatal, onset of prenatal care, alcohol/tobacco/substance use during pregnancy.
v. Include time of ruptur of memberane in hours and how it was confirmed, if induction used (mechanical vs. chemical).
vi: Include fetal U/S results: fetal position, fetal anatomy, fetal size, amniotic fluid volume, placenta location.
vii: Report Results of vaginal exam: dilation, cervical position, cervical effacment, station.

b. Gynecological history:

i. Age of menarche
ii. Date of last menstrual period (LMP)
iii. Frequency of menstruation - cycles can be anywhere from 21-35 days in length
iv. Length of menstruation
v. Features of menstruation – Menorrhagia? It is important to quantify because what is “heavy” to one woman may be light to another. Dysmenorrhea? If so, do they require medication? You can use LMOPQRST.
vi. Is the patient sexually active? If so, what form(s) of contraception are they using? How long?
vii. History of sexually transmitted diseases – if positive, were they treated? When? Partner as well

Developmental Milestones Chart

Denver II