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Admission note

The first inpatient note of the stay: presenting complaint through to plan, in the order a reader needs it.

Start free trial See the worked example

About the admission note

The admission note is the first entry in the inpatient record, and every later note in the stay refers back to it. It carries the reason the patient is here, the relevant background, what was found on examination and the working plan, in the order a reader needs them. At setup it is shaped to your own section order and phrasing, not left as a generic form.

The initial inpatient note: background history, presenting complaint, examination by system, investigations, impression and plan.

The template, filled in.

The section headings below are the shape this template lays down. The content is a synthetic worked example, not a real patient, so you can see what a filled document looks like before you sign up.

Admission note Admission note · worked example Demo patient · synthetic record
Drafted · For sign-off
DEMO PATIENT · SYNTHETIC DATA
Presenting complaint Three days of increasing shortness of breath and a productive cough. Background Hypertension and type 2 diabetes, independent at home, non-smoker. Examination Afebrile, saturating 94 per cent on room air, right basal crackles. Investigations Chest film pending. CRP 86, white cells mildly elevated. Impression Community-acquired pneumonia. Plan Commence IV antibiotics, oxygen as required, daily review.
Drafted by aurii. Reviewed and signed by the treating clinician before anything is filed.

Every template passes the clinical board before release. A template controls the shape of a document, nothing more: the impression and the plan are yours, and no document built from it is filed, sent or billed until you sign.

More in Notes and rounds

Progress note Ward round note Discharge note Consult · basic SOAP

Your paperwork, in your shape.

Start the trial, bring a typical list, and the admission note is shaped to your round before you sign your first one. See the full template set, or how the whole product works on the product page.

Start free trial All templates

hello@aurii.com.au · Australian data residency // always doctor-signed