Inpatient reference · Note templates

Clinical note templates

Paste-ready inpatient note templates for the 9 formats you'll write on the wards. Each template has placeholder brackets to fill in. Use the AI generator to pre-fill the note from a short patient blurb — always verify every field before signing.

Educational template — verify content against institutional protocol and preceptor guidance before signing. Never invent labs, vitals, or diagnoses.

Template

History & Physical (admission)

HISTORY & PHYSICAL — ADMISSION

Date/Time: [YYYY-MM-DD  HH:MM]
Attending: [Attending]        Service: [Service]        Resident: [Your name]

CHIEF COMPLAINT
[One sentence in the patient's own words]

HISTORY OF PRESENT ILLNESS
[Age] [sex] with [PMH highlights] presenting with [duration] of [symptom].
- Onset / trigger:
- Character / location:
- Aggravating / alleviating:
- Associated symptoms:
- Prior work-up / treatment:
- Reason for admission:

PAST MEDICAL HISTORY
- [Condition 1] — [year, control]
- [Condition 2]

PAST SURGICAL HISTORY
- [Procedure — year]

MEDICATIONS (home)
- [drug + dose + route + frequency]

ALLERGIES
- [drug — reaction]

SOCIAL HISTORY
- Tobacco / alcohol / substances:
- Occupation / living situation:
- Advance directive / code status: [Full code / DNR / DNI]

FAMILY HISTORY
- [Relevant conditions in first-degree relatives]

REVIEW OF SYSTEMS
Constitutional: [fever/chills/wt loss]
CV / Resp / GI / GU / MSK / Neuro / Psych / Skin: [pertinent +/-]

PHYSICAL EXAM
Vitals: T [ ], HR [ ], BP [ ], RR [ ], SpO2 [ ] on [O2 device]
General: [alert, NAD]
HEENT: 
Neck / Lymph:
CV:
Resp:
Abd:
Ext:
Neuro:
Skin:

LABS
CBC: WBC [ ] Hgb [ ] Plt [ ]
BMP: Na [ ] K [ ] Cl [ ] HCO3 [ ] BUN [ ] Cr [ ] Glu [ ]
LFTs, coags, troponin, lactate, procalc as indicated

IMAGING / STUDIES
- [CXR / CT / EKG findings]

ASSESSMENT & PLAN
[Age] [sex] with [problem list] admitted for [primary reason].

# Problem 1 — [primary diagnosis]
- Assessment: [brief reasoning]
- Plan: [labs, imaging, meds, monitoring, consults]

# Problem 2 — 
- 
- 

# Problem 3 — 
- 
- 

Code status: [Full code / limitations]
Disposition: [Floor / step-down / ICU]
Anticipated LOS: [days]

Educational template — verify against institutional protocol and preceptor guidance before signing.

AI Note Generator

Pre-fill H&P · Claude 4.5

Patient blurb

All templates

RxFlow Review · History & Physical (admission)

Educational template — verify with pharmacy and institutional protocol before signing.

HISTORY & PHYSICAL — ADMISSION

Date/Time: [YYYY-MM-DD  HH:MM]
Attending: [Attending]        Service: [Service]        Resident: [Your name]

CHIEF COMPLAINT
[One sentence in the patient's own words]

HISTORY OF PRESENT ILLNESS
[Age] [sex] with [PMH highlights] presenting with [duration] of [symptom].
- Onset / trigger:
- Character / location:
- Aggravating / alleviating:
- Associated symptoms:
- Prior work-up / treatment:
- Reason for admission:

PAST MEDICAL HISTORY
- [Condition 1] — [year, control]
- [Condition 2]

PAST SURGICAL HISTORY
- [Procedure — year]

MEDICATIONS (home)
- [drug + dose + route + frequency]

ALLERGIES
- [drug — reaction]

SOCIAL HISTORY
- Tobacco / alcohol / substances:
- Occupation / living situation:
- Advance directive / code status: [Full code / DNR / DNI]

FAMILY HISTORY
- [Relevant conditions in first-degree relatives]

REVIEW OF SYSTEMS
Constitutional: [fever/chills/wt loss]
CV / Resp / GI / GU / MSK / Neuro / Psych / Skin: [pertinent +/-]

PHYSICAL EXAM
Vitals: T [ ], HR [ ], BP [ ], RR [ ], SpO2 [ ] on [O2 device]
General: [alert, NAD]
HEENT: 
Neck / Lymph:
CV:
Resp:
Abd:
Ext:
Neuro:
Skin:

LABS
CBC: WBC [ ] Hgb [ ] Plt [ ]
BMP: Na [ ] K [ ] Cl [ ] HCO3 [ ] BUN [ ] Cr [ ] Glu [ ]
LFTs, coags, troponin, lactate, procalc as indicated

IMAGING / STUDIES
- [CXR / CT / EKG findings]

ASSESSMENT & PLAN
[Age] [sex] with [problem list] admitted for [primary reason].

# Problem 1 — [primary diagnosis]
- Assessment: [brief reasoning]
- Plan: [labs, imaging, meds, monitoring, consults]

# Problem 2 — 
- 
- 

# Problem 3 — 
- 
- 

Code status: [Full code / limitations]
Disposition: [Floor / step-down / ICU]
Anticipated LOS: [days]

Educational template — verify against institutional protocol and preceptor guidance before signing.