SAMPLE DOCUMENTATION

TEMPLATES
UPHS – Department of Medicine
Initial Hospital Visit/Inpatient Consult Note

www.hospitalmedicine.org
UPHS – Department of Medicine
Initial Hospital Visit/Inpatient Consult Note

Date: ______________ Time: ______________

■ Initial Visit ■ Consult - Requesting Physician:_________________
(Requires all 3 components: History, Exam, and Medical Decision Making)
(1) HISTORY: Patient Name:
Chief Complaint/HPI: 1. (Consult: Level 3-5 = >4 elements; Level 1-2 = <3) Allergies: ■ NKDA
2. (Admit: 4 elements required)
(location/quality/duration/timing/severity/context/modifying factors/associated signs
and symptoms)
■ unable to obtain (indicate reason) Medications: ■ OTC Meds
■ Supplements
(Vits/Herbals)

■ I have considered the home

medication list when writing
admission orders.

ROS: 1. (Consult: Level 4-5 = 10; Level 3 = 2-9; Level 2 = 1; Level 1 = 0) ■ Remainder Negative ■ unable to obtain (indicate reason)
2. (Admit: Level 2-3 = >10; Level 1 = 2-9)
N1 Comments (positive or pertinent negs) N1 Comments
Constitutional Integumentary
Eyes Musculoskeletal
Ears/Nose/Mouth/Throat Neurologic
Respiratory Psychiatric
Cardiovascular Endocrinologic
Gastrointestinal Hematologic
Genitourinary Immunologic
(Address ALL Histories; the term “non-contributory” is acceptable, when appropriate)
Past Medical and Surgical History: ■ unable to obtain (indicate reason) ■ Non-contributory FH: ■ Non obtainable ■ NC

SH: ■ Non obtainable ■ NC

■ ETOH
■ Tobacco use ________ pk yr
■ IVDA/Last use ________
■ Occupation:
■ Living Situation
■

*136568*
*136568* Page 1 of 4 136568-3 AEL 1/2006
Date _____________________________
MULTI-SYSTEM EXAMINATION: (Consult: Level 4-5 = 2 boxes in 9 systems; Level 3 = any 12; Level 2 = any 6; Level 1 = any 5)
Elaborate abnormal findings (Admit: Level 2-3 = 2 boxes in 9 systems; Level 1 = any 12)

Constitutional: T: _____ P: _____ ■ reg BP: _____ ■ sit RR: _____ WT: _____ HT: _____ ■ See Flow Sheet
■ irreg ■ supine

Appearance:

Eyes: ■ no scleral icterus ■ PERRLA ■ nl fundus exam

E/N/M/T: ■ nl hearing ■ nl external canals/tympanic membrane

■ nl teeth, lips gums ■ clear oropharynx

Neck: ■ nl appearance and movements; nl JVP

■ trachea midline
■ no thyroid enlargement, masses

Respiratory: ■ symmetrical chest expansion and respiratory effort

■ clear to auscultation and palpation
■ nl percussion

Breast: ■ nl breast symmetry ■ no masses/tenderness of breasts or axillae

Cardiovascular: ■ nl sounds; no murmurs, gallops or rubs ■ no JVD

■ no carotid bruits ■ nl PMI; no thrill
■ nl pulses (indicate) ■ femoral ■ pedal ■ other:

Abdominal: ■ no tenderness; nl sounds ■ no hernias present

■ no hepatosplenomegaly ■ nl digital rectal exam
■ neg hemoccult test

Lymphatic: no adenopathy: ■ cervical ■ supraclavicular ■ axillary ■ inguinal

Musculoskeletal: ■ nl gait ■ no clubbing, cyanosis

■ nl symmetry, ROM, strength and tone

Skin: ■ no rashes or ulcers ■ no nodules

Neuro: ■ nl cranial nerves ■ nl reflexes ■ nl sensation

Psych: ■ alert, oriented to person, place, time

■ intact memory ■ nl affect, judgement, insight

Genitourinary: MALE: ■ nl scrotum; no tenderness or masses ■ nl penis

■ nl digital rectal exam of prostate

FEMALE: (pelvic exam with or without specimen collection for smears and cultures)
■ nl external genitalia and vagina ■ no urethral tenderness
■ nl bladder; no masses or tenderness
■ nl cervix; no lesions or discharges ■ nl uterus
■ nl adnexa/parametria

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Date _____________________________
Data Review:

Assessment and Plan:

Resident/Medical Student Signature: _____________________________ Date: ________ Time: ________

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Date _____________________________
Attending Supplement: (Minimum 1 element from 3 components: history, exam, and medical decision making).
I saw and examined the patient, and I agree with note by Dr:_________________________________________________________.
■ Discussed w/other provider: ________________
■ Attending review:
■ Lab Data
■ Radiology
■ OSH records
■ Old Records
■ Diagnostic Tests Ordered
■ Radiology
■ Cardiology
■ Old Records
■ Other

Attending Signature/Print:________________________________________________________ Date: _________ Time: _________

C. Crumlish MD A. Fuld MD T. Hecht MD C. Jaipaul MD S. Krekun MD

J. Myers MD S. Pickering MD J. Savitz MD D. Steinberg MD S. Swift MD K. Williams MD

Total Attending Floor Time (min): ____ Counseling/Coordination Time (>50% Total Floor Time, Face to Face w/Pt/Family):__________

Consult: ■ 99251 (20 min) ■ 99252 (40 min) ■ 99253 (55 min) ■ 99254 (80 min) ■ 99255 (110 min) ■ Observation Day
Initial: ■ 99221 (30 min) ■ 99222 (50 min) ■ 99223 (70 min) ■ Critical Care: Total Cumulative Time ________________
■ Prolonged Care: Time: ________ (Face to Face with Patient only) ■ -25 (Separately identifiable E/M service on procedure day)
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