Senior Admission Note (“The Blue Note”)
The Senior Admission Note is a REQUIRED note written on EVERY patient admitted to the medical team by the senior resident caring for the patient (only exception is when the senior resident writes the H&P themselves). The Senior Admission note, which is written at the time of admission, complements the H&P done by the intern or student and includes:
The name of the patient along with the medical record number and date and time.
A brief discussion summarizing the presentation of the patient on admission including the relevant: history of present illness, past medical history, social history, family history, physical exam, and laboratory and diagnostic imaging results.
The main emphasis of the note should be on the assessment and plan for the main patient problems.
Discussion with Attending of record should be documented
Must be legible and well written so to avoid any misunderstanding by the reader
Must have a time and date and be signed on each page by the author in legible fashion.
An example of the format of a Senior Admission Note is below.
Patient sticker
Summary of presentation (
History of present illness: BRIEF synopsis
Past Medical, Social and family history
These items must be confirmed by the senior. If they are accurate the note can say “Please refer to intern H&P” for past medical, family, and social history.
Physical exam
Physical Exam does not need to be re-written. The senior note should comment only on the pertinent positives.
Lab and imaging studies
Senior note can refer to the intern note for labs. “Please see intern note for lab and imaging studies.”
Assessment and Plan
The major problems should be addressed with an assessment and plan for each.
The Senior note may refer to the intern note for the minor problems “for rest of problems please see intern note details”
Details regarding the discussion of the case with the Attending of record
Signature with printed name and pager number
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(WORKING ACROSS THE SOUTH WEST) APPRAISAL GUIDE FOR SENIOR
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