Patient Admission 📝
Comprehensive guide for patient admission and clerking. Specialty-specific history, examination, and investigations for NCHDs admitting patients.
🔍 Before You Start
- Check triage/referral details or reason for admission.
- Note any red flags (e.g. chest pain, shortness of breath, confusion).
- Ensure patient is stable—address ABCs if unwell.
🗣️ History
- Presenting complaint – what brought them in today?
- History of presenting complaint – timeline, severity, progression.
- Past medical history – major illnesses, surgeries, hospitalisations.
- Drug history – current meds, allergies (including reactions).
- Family history – relevant hereditary conditions.
- Social history – smoking, alcohol, living situation, supports.
- Systems review – pick up anything missed.
🩺 Examination
- Vitals: HR, BP, Temp, RR, O2 sats.
- General appearance: well/unwell, cachectic, jaundice, confusion.
- Systematic exam: Focus based on complaint but examine broadly.
- Neurological screen if altered or relevant complaint.
🧪 Initial Orders
- IV access and admission bloods: FBC, U&E, CRP, LFTs, Coag, Trop, Glucose, ± others.
- ECG if cardiac history, palpitations, chest pain.
- Urinalysis ± culture.
- CXR if respiratory complaint or fever.
- Cultures if signs of infection.
📝 Documentation
- Clearly document history, exam, initial impression.
- Working diagnosis and differentials.
- Plan: investigations, management, referrals.
- Escalation plan / ceiling of care - discuss with seniors (e.g. for frail or elderly).
📦 Other Essentials
- Medication reconciliation—match chart with patient's meds.
- Write up regular meds + PRN analgesia/laxatives/antiemetics.
- Write up admission medications (e.g. IV fluids, antibiotics).
- Fluid balance: oral intake? Need IV fluids?
- Notify team if complex or unstable.
Specialty-Specific Admission Guide
Select a specialty for focused history, examination, and investigations
Select a specialty above to view specialty-specific admission guidance
Note Template
Ready-to-use clinical note structure
🕒 08 / 10 / 2026 — 16:05 Medical / Surgical Admission Note Patient: [age] [sex] Admission Dx: [reason for admission] PMHx: [relevant comorbidities / secondary diagnoses] 🧾 Hx: • Presenting complaint and history • Past medical and surgical history • Allergies and medications • Social history and support 🩺 Exam: • Full systems examination • Vitals: HR __ BP __ Temp __ RR __ SpO₂ __ • Mental status and GCS 📋 Impression: Working diagnosis and differential 📌 Plan: • Initial investigations and bloods • Imaging and specialist referrals • Treatment commenced • Monitoring and escalation plan 👤 [Your Name], [Role] IMC: _______
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