Admission Note

入院病歷，在患者入院時書寫，常聽到大家說的接 new pa (接 new patient) ，寫的就是 admission note。 由chief complaint, present illness, past history, review of system, physical examination, 檢驗/檢查報告, Diagnosis 與 plan等部分所組成。

Chief Complaint

• 病人的主述
• 不要使用醫學專有名詞
• 格式：最主要症狀 + duration
• 通常以一個最主要的症狀為主

Example

Intermittent fever for 2 days

常見錯誤

1. 用病人的口吻書寫：

不要使用醫學專有名詞

→ 患者會說他發燒、咳嗽，不會說他 pneumonia

2. 寫入太多 Complaint

「Chief」complaint 代表最主要的一個問題。

患者說他發燒、咳嗽、流鼻水，就挑最困擾的問題寫就可以了

Fever for 2 days

3. Duration 表示方法

個人傾向 Fever for 2 days 會比 Fever since 6/7 更直觀

Chief complaint 應簡短呈現這次就醫的主要原因，詳細病程則放在 Present Illness。

Present Illness

Present illness 可以依照以下順序撰寫：

順序	內容
1. Patient profile	性別、年紀
2. Underlying／related history	與此次病況相關的過去病史
3. Chief complaint	使用 LQQOPERA 描述症狀
4. ER triage	TPR 與其他 vital signs
5. Physical examination	重要 positive 與 negative findings
6. Laboratory findings	重要檢驗結果
7. Imaging findings	X-ray、ultrasound、CT 等
8. Impression	Under the impression of…

Present Illness Example

This is a 62-year-old man with past medical history of:

1. Hypertension
2. Type 2 diabetes mellitus, under regular medical treatment

According to the patient and chart records, he had developed right upper quadrant abdominal pain accompanied by nausea and vomiting for 2 days. The pain was persistent and aggravated after meals. He denied yellowish discoloration of the skin or sclerae. Due to persistent symptoms, he visited our ER for further evaluation.

At ER triage, vital signs showed Temp. 38.2°C, HR 102 bpm, RR 20 breaths/min, BP 135/85 mmHg. Physical examination revealed RUQ tenderness with a positive Murphy’s sign, without muscle guarding or rebound tenderness.

Laboratory data showed leukocytosis with a WBC count of 14,000/μL and an elevated CRP level of 7.8 mg/dL. Liver biochemical tests, including total bilirubin, AST, ALT, and ALP, were within normal limits.

Abdominal sonography was arranged and demonstrated gallstones with gallbladder wall thickening and pericholecystic fluid.

Under the impression of acute calculous cholecystitis, the patient was admitted to our general surgery ward for laparoscopic cholecystectomy on 2026/06/08.

常見錯誤

Present illness 並不只需要列出 positive findings。

Negative findings 往往才是評斷病歷書寫者功力的重點。

光看列出的 negative findings，就可以看出書寫者：

• 考慮了哪些 differential diagnoses
• 試圖 rule out 哪些疾病

Past History

醫院系統通常會有類似以下的模板供填寫。

Past Medical History:
1.
2.

Past Surgical History:

1.
2.

Medication History:

1.
2.

Allergy History:

Social and Personal History:

- Cigarette smoking: Denied
- Alcohol consumption: Denied
- Betel nut chewing: Denied
- Recent travel, contact, or cluster exposure: Denied

Family History: Non-contributory.

Review of Systems

醫院系統會有類似以下的模板供填寫

General

Fever (−), chills (−), diaphoresis (−), irritability (−), fatigue (−)

Skin

Rash (−), pruritus (−), cyanosis (−), jaundice (−), hyperpigmentation (−)

Eyes

Blurred vision (−), visual loss (−), diplopia (−)

Respiratory

Cough (−), sputum production (−), shortness of breath (−), dyspnea (−), wheezing (−)

Cardiovascular

Chest tightness (−), chest pain (−), palpitations (−), syncope (−), orthopnea (−), intermittent claudication (−)

Gastrointestinal

Poor appetite (−), dysphagia (−), hematemesis (−), abdominal fullness (−), abdominal pain (−), constipation (−), diarrhea (−), hematochezia (−), melena (−)

Genitourinary

Urinary frequency (−), urgency (−), nocturia (−), dysuria (−), oliguria (−), gross hematuria (−), tea-colored urine (−), urinary retention (−), urinary incontinence (−), flank pain (−)

Musculoskeletal and Extremities

Limb swelling (−), local warmth (−), limb pain (−), limited range of motion (−)

Neurologic

Disturbance of consciousness (−), memory impairment (−), vertigo (−), dizziness (−), incoordination (−), sensory changes (−), paralysis or paresis (−)

Psychiatric

Depression (−), anxiety (−)

Physical Examination

醫院系統會有類似以下的模板供填寫

Basic Information

Height: _____ cm
Body weight: _____ kg

Vital signs:
Temperature: _____ °C
Heart rate: _____ bpm
Respiratory rate: _____ breaths/min
Blood pressure: _____ mmHg
SpO₂: _____ %

Physical Examination Template

1. General appearance:
   Acutely ill-looking.

2. Mental status:
   Alert and oriented.
   GCS: E4V5M6.

3. Oxygenation status:
   No cyanosis on room air.

4. Eyes:
   Conjunctivae: Pink.
   Sclerae: Anicteric.

5. Head:
   No traumatic lesions.

6. Neck:
   Supple.
   No goiter.
   No jugular venous distention.
   No carotid bruit.

7. Chest:
   Inspection: No use of accessory muscles.
   Palpation: Symmetric chest expansion bilaterally.
   Auscultation: Clear breath sounds bilaterally.

8. Heart:
   Regular rate and rhythm.
   No audible murmur.

9. Abdomen:
   Inspection:
   Spider nevi (−).
   Grey Turner’s sign (−).
   Cullen’s sign (−).

   Palpation:
   Abdomen soft.
   Tenderness (−).
   Rebound tenderness (−).
   Muscle guarding (−).
   Murphy’s sign (−).

   Percussion:
   Ascites (−).
   Hepatomegaly (−).
   Splenomegaly (−).

   Auscultation:
   Bowel sounds normoactive.

10. Back:
    No costovertebral angle tenderness.
    No flank soreness.

11. Extremities:
    No cyanosis.
    Full range of motion.
    Pitting edema (−).

12. Skin:
    Normal appearance and turgor.
    No rash or ecchymosis.
    Surgical scar (−).

13. Lymph nodes:
    No cervical, supraclavicular, axillary, or inguinal lymphadenopathy.

Impression

Impression 是目前的入院診斷。

例如：

Impression:

1. Acute calculous cholecystitis
2. Hypertension
3. Type 2 diabetes mellitus

如果診斷尚未完全確定，可以寫：

1. Right upper quadrant abdominal pain, suspected acute cholecystitis

或：

1. Fever, cause to be determined

Plan

Plan 可以分為三個部分。

Therapeutic Plans

預計進行的治療與處置，例如：

• 預計接受的手術或 procedure
• 目前使用的藥物
• 使用何種 antibiotics
• IV fluid
• Analgesics
• NPO
• Oxygen therapy
• Glucose control

Educational Plans

• 疾病衛教
• 治療方式說明
• 生活與飲食注意事項
• SDM 討論過程
• 手術或 procedure 的風險與效益

Follow-up Plans

• Pending culture results
• Pending pathology report
• Follow-up laboratory data
• Follow-up imaging
• Consultant recommendations
• Treatment response