General Practitioner Template

Generic Hospital Admission Notes

A professional General Practitioner template for healthcare professionals.

About this template

The Generic Hospital Admission Notes template is an essential tool for General Practitioners and other healthcare providers to efficiently document patient admissions. This comprehensive template captures critical patient information, including personal details, insurance information, and medical history, ensuring a smooth transition from referring facilities to hospital care. By using this template, clinicians can streamline the admission process, reduce errors, and improve patient care coordination. Ideal for use in Heidi, this template ensures all necessary details are captured for a successful hospital admission.

Preview template

Hospital Information Referring Facility: St. Mary's Hospital Phone: 020 7946 0958 Fax: 020 7946 0959 Contact Person: Dr. Emily Carter Date of request: 1 November 2024 Patient Medical Record Number: 123456789 Patient Data Patient Name: John Doe Date of Birth: 15 March 1980 Gender: Male Social Security Number: 987-65-4321 Marital Status: Married Address: 123 Elm Street, London, SW1A 1AA Home/Cell Number: 07123 456789 Other contact Number: 07123 987654 Mother’s First Name: Mary Father’s First Name: Robert Insurance Details Insurance Plan: HealthFirst Plan ID/Group Number: HF123456 Medicaid CIN Number: AB123456C Medicare Number: 1234-567-890 Is the patient on an HMO plan?: Yes Plan name: HealthFirst HMO Admission Notes Referring Physician Name: Dr. Thomas Kelly UPIN Number (for diagnostic services): A12345 Clinic Referred: City Health Clinic Diagnosis: Hypertension ICD 9 Code: 401.9 Request to rule out/evaluate patient for: Cardiovascular assessment Time frame physician is seeking for appointment: Within 2 weeks Additional Information: Patient has a history of high blood pressure and is currently on Lisinopril. Recent lab results show elevated cholesterol levels. No known allergies. Patient appointment day/time preference: Monday mornings

Hospital Information Referring Facility: [name of referring facility] Phone: [contact phone number] Fax: [fax number] Contact Person: [name of contact person] Date of request: [date of request] Patient Medical Record Number: [medical record number] Patient Data Patient Name: [patient's full name] Date of Birth: [patient's date of birth] Gender: [Male/Female] Social Security Number: [social security number] Marital Status: [Married/Single/Widowed/Divorced] Address: [patient’s full address] Home/Cell Number: [patient’s phone number] Other contact Number: [alternate phone number] Mother’s First Name: [mother’s first name] Father’s First Name: [father’s first name] Insurance Details Insurance Plan: [insurance provider name] Plan ID/Group Number: [insurance plan ID/group number] Medicaid CIN Number: [Medicaid CIN number] Medicare Number: [Medicare number] Is the patient on an HMO plan?: [Yes/No] Plan name: [HMO plan name] (Please remind patients to bring their referrals on the date of appointment.) Admission Notes Referring Physician Name: [name of referring physician] UPIN Number (for diagnostic services): [UPIN number] Clinic Referred: [name of clinic] Diagnosis: [diagnosis] ICD 9 Code: [ICD 9 code] Request to rule out/evaluate patient for: [reason for referral] Time frame physician is seeking for appointment: [preferred appointment time frame] Additional Information: (attach reports/lab results, medications taken/exams done/history etc. pertinent to patient care) [relevant medical history, test results, medications, or other pertinent clinical details] Patient appointment day/time preference: [preferred appointment day/time] (Please send completed admission notes back - any incomplete detail will not be accepted) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information to include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)

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