How do you write admission and discharge notes?

[Hemichordate]

Is it the same as writing SOAP notes?

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[DrBowtie]

Admission note is H&P including cc, HPI, ros, pmhx, pshx, fmhx, sohx, meds, allergies, PE, labs, imaging, A/P. Some specialties have added sections like OB.

DC summary is essentially a summary of the hospitalization. Dates of admit/DC. Primary team, consults, procedures/major imaging. Summary of HPI, admit/DC diagnosis. Then basically summarize the hospital course of each problem. Place of disposition and discharge medication list.

 

[D elegans]

Some things may vary a bit by institution. Our EMR system has many templates to use for all kinds of notes. I would just look at whatever the residents are using on whatever service you're on and go off of that. For instance, surgery notes were much different (shorter and in incomplete sentences) compared to internal med notes