Admission Note (Template)
Paediatric History and Physical Examination (as previous), and:
INVESTIGATIONS
• Blood work: CBC, electrolytes, glucose, renal function, liver function
• Microbiology: blood, urine, CSF, nasal, stool cultures
• Imaging: x‐ray, ultrasounds, CT, MRI
• Pathology: if relevant
IMPRESSION/ASSESSMENT (IMP)
This is a (year old) (sex) [who is previously healthy] or [with a history of
XYZ] presenting with (brief summary of pertinent positive/ negative
symptoms on history, signs on physical examination and relevant
investigations) with a most likely diagnosis of _____________.
DIFFERENTIAL DIAGNOSIS (DDX)
May chose to use broad categories by system or process when considering
specific diagnoses (i.e., use of VITAMINS ACD acronym)
Vascular, Infectious/Inflammatory, Traumatic/Toxin, Autoimmune/
Acquired, Metabolic/Medication, Iatrogenic/Idiopathic, Neoplastic, Social,
Allergic, Congenital, Degenerative, Endocrine
MANAGEMENT PLAN/ADMISSION ORDERS (PLAN)
• Admit: Admit to (your service) under (your consultant today).
• Diagnosis: This is what you suspect they have. (e.g., Asthma)
• Diet: DAT (diet as tolerated) NPO (nothing per os/by mouth; if going
for surgery or procedures), Breast feed ad lib, Formula, Tube feeds
(NG‐tube, G‐tube, GJ‐tube)
• Activity: AAT (Activity as Tolerated), bedrest
• Vital Signs: VS (Vital Signs q8‐12h = HR, RR, BP, O2 sat, Temp), VS
q4h (if particularly sick patient requiring more frequent vitals),
Special parameters (e.g., Neurological vitals)
• Monitoring: ECG, oxygen saturation, Ins & Outs, daily weights
• Investigations
o Bloodwork (Hematology, Biochemistry)
o Microbiology
o Imaging
o Consults
• Drugs
o Past: Medication Reconciliation – all regular medications (may not
need all; e.g., no need for previous PO antibiotics if starting IV)
o Present: what does patient need now
o Future: anticipate what patient may need; e.g., fever, nausea, pain,
stools