How to Write an Admission Note: Part 1 (The History)

In this video from the University of Calgary, you will learn how to organize and document the history component of an admission or other major history & physical patient encounter. Part 2 (physical, diagnosis and plan) is available at • How to Write an Admiss... . ** For other great clinical learning resources, check out sharcfm.com, the Shared Canadian Curriculum in Family Medicine!

[@eudloq4037]

watching this before i begin my first medical scribe session, thank you so much. very concise and broken down

[@med8523]

thank you.. as an immigrant physician, this is helping me a lot. I appreciated.

[@davidkeegan2702]

You are most welcome! I wish you the best in your professional journey in your new country!

[@dhananjay76]

Thank you very much sir for making it so simple and interesting, easy to follow

[@oludamilolaidowu3880]

Thanks for this video Dr. Keegan

[@dkcalgary]

You are most welcome! DK

[@sarahusain8420]

Thank you so much for making these awesome videos! Can you do "Discharge summary" video please ??

[@dkcalgary]

Hi - thanks for your feedback! That's on my to-do list when I get a chance. Thanks! DK

[@dkcalgary]

Hi, Thanks for the feedback. Once I get a chance, a Discharge Video will be made! DK

[@thita.maprang8525]

Sara Husain ，

[@noahnelson6385]

Great stuff, thx doc!

[@thehusbandofstardomfamily6152]

Clarity, detail and accuracy.

[@justinesportsmedicine9379]

Concise and Elegant. Wonderful intro to clinical diagnosis. It was obvious to me that this was not an all inclusive course, however very effective. I have a request as a U.S. Physician, is it possible to repeat this topic as applied to the following; First, considerations when reviewing the H & P taken by Nurse Practicioner, Physician Assistants and Training Medical Residents/Students. My point is to highlight the physicians responsiblities with the H & P when data is collected by someone else. Lastly, considerations when taking the H & P by telemedicine if differences exist. Regards

[@dkcalgary]

Hi, sorry for the delay. There are specific regulations in the US about how you, as a physician, are to rely upon the health data gathered and recorded by others. I believe it's the Medicare rules which govern it. As a Canadian, I can't speak to some of your specific questions. In general, though, all clinicians should confirm critical history or physical pieces ourselves. I happily trust the teams I work with, and will double-check things when I am having to make a key decision or recommendation.

[@moshfiqurchowdhury3698]

You are a superman sir.

[@dkcalgary]

Dear Moshfiqur, wow! Er, does that mean I don't get to be in a MCU movie? Thanks! David :)

[@AdrienLegendre]

For HPI, always use correct grammar, spelling and only standard abbreviations; the medical record is a legal document, not a personal diary entry. The provider excludes any data not contributing to diagnosis or treatment. Identify, rank and list each problem as a separate header; one header per line, vertically spaced, most to least important from top to bottom. Below each header, create a single 6 sentence paragraph: 1) symptom list and time course, 2) list of relevant absent symptoms, 3) list ameliorating/aggravating factors, 4) list potential relevant etiological/risk factors, 5) list relevant diagnostic tests and results, 6) list relevant treatments received and treatment response(s). Example: "This 22 year old woman has once monthly, 2-8 hour duration, right or left frontal-temporal, throbbing head pain accompanied by nausea, light and sound sensitivity, beginning at 18 years of age. She denies vomiting, tearing, eyelid droop, or visual aura. Sleep relieves head pain. Brain MRI without contrast (January 15, 2019) was normal. Sumatriptan relieves headaches in 50% of cases; topiramate was ineffective for headache prevention."

[@davidw.9711]

I use to abbreviate diarrhea with D and vomiting with V, I know this might confuse other colleagues but are there generally accepted abbrev.? thanks

[@dkcalgary]

Hi, V and D are often used (and "N" for nausea), but the problem is that they're not universal. It's a problem with medicine: how to be efficient and safe at the same time. I have personally found that it doesn't take up much time to write out "vomiting" etc, and makes things clearer to the reader. DK

[@B0tsie]

I always use n/v/d. Nausea, vomiting, diarrhea.

[@kalungirenah650]

👍👍

[@RubiksBotES]

He writes at an incredibly fast pace

[@dkcalgary]

:) I teach with whiteboards, so I guess I figured how to do this quickly.

[@dr.maysaaalharbi.5480]

Amazing channel thank you so much sir.but why did you stop 💔I hope everything is fine

[@dkcalgary]

Thanks so much. Just very, very busy. As soon as I can, I will be back with more. :)

[@thehusbandofstardomfamily6152]

Recreation use Cig/etoh/drugs Yessssssss!!!!!!! Social context is important! 👁can save you time, and identify with their real issue. Especially when dealing idiopathic illnesses and mental disorders.

[@dragondanceable]

please. TK

[@hcsvcw9853]

1

[@Somaye40]

Thanks a lot. But you forget family history.

[@dkcalgary]

Yikes! I simply cannot believe I forgot FamHx!!?!! I will add a note into the video to make that clear, once I remember how to do it. Thanks! DK

[@dkcalgary]

Hi, Yikes! How did I manage to do that. I'll hack into the video and add it in as a visual cue! Thanks! DK

[@lhelms2850]

@@dkcalgary I love and appreciate your HUMILITY... Thank you. :))

[@dkcalgary]

Hi! Imm just trying to do my best like everyone else on this planet we share. I cannot believe I forgot FamHx!?! :)

[@DaKeWLMaN]

Wasn't very accurate from the time you wrote accurate incorrectly

[@dkcalgary]

Hi! Ha! I'll have to re-watch the video to see if I did actually incorrectly write accurate! DK

[@thehusbandofstardomfamily6152]

Pediatrics= genetic and pedigree.

[@thehusbandofstardomfamily6152]

CULTRAL/RELIGION...+++++