HOSPITALIST ADMISSION NOTE REFERRED BY: Dr  ID: [provide age, where the live and family physician] REASON FOR ADMISSION: [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: 1. MOST [current MOST status] PREVIOUS MEDICAL HISTORY: 1.  2.  PREVIOUS SURGICAL HISTORY: 1.  2.  ALLERGIES:  HOME MEDICATIONS: 1.  2.  SOCIAL HISTORY: ADL:  Living Conditions:  Support:  Family:  Substances:  Alcohol:  Occupation:  Drivers License: [yes] Marital Status:  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: 1. [List all pertinent investigations and mention positive and negative findings for each] 2.  SUMMARY: [Generate a problem statement that can be carried over to the progress note. This is a summary of the problems identified.] ASSESSMENT & PLAN: 1.  DISPOSITION: 1. Admit to  2. VTE:  3. Diet:  ELOS:  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. Dr 
HOSPITALIST PROGRESS NOTE MOST:  SUMMARY: [Age, where patient lives and family physician. Overview of current issue. Can be updated daily and should provide any physician with the background story around the current admission] TODAY: [Date} [short entry about the day vitals, subjective, objective, pertinent investigations] ASSESSMENT AND PLAN: 1. [Diagnosis] - [Info regarding details around condition, pertinent investigations, consultations, plan] 2. [Diagnosis] - [Info regarding details around condition, pertinent investigations, consultations, plan] RESOLVED ISSUES:  VTE:  ELOS/ BARRIERS TO DISCHARGE:  PREVIOUS MEDICAL HISTORY: [Import previous medical history and keep it updated to be transferred to discharge summary] This note was created with voice recognition software and may contain some errors. If anything is unclear, please do not hesitate to contact me. Dr 
HOSPITALIST DISCHARGE SUMMARY DATE OF ADMISSION:  DATE OF DISCHARGE:  MOST:  REASON FOR ADMISSION: [What diagnosis is on history and physical] MOST RESPONSIBLE DIAGNOSIS: [Insert problem list] RESOLVED ISSUES:  PREVIOUS MEDICAL HISTORY: [Import from progress note] DISCHARGE MEDICATIONS: [Indicate changes in bold] SUMMARY OF ADMISSION: [Provide a one paragraph summary, can import summary and just add information] FOLLOW-UP: 1.  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. Dr  Vernon Jubilee Hospitalist
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