Internal Medicine — Hospital Admission H&P Template

The Hospital Admission History and Physical (H&P) Template is a comprehensive documentation tool for hospitalists, internal medicine physicians, and medical residents admitting patients to the hospital. This template meets Joint Commission and CMS requirements for complete admission documentation within 24 hours of inpatient admission, systematically capturing all required elements for medical decision-making and care planning. The template includes structured sections for chief complaint and reason for admission, detailed history of present illness with pertinent emergency department course, complete past medical and surgical history, medications reconciliation, allergies, family and social history with relevant risk factors, comprehensive review of systems, thorough physical examination by body system, review of admission laboratories and imaging, assessment with problem list and ICD-10 codes, and detailed admission orders and treatment plan for each active problem. This standardized format ensures regulatory compliance, supports accurate DRG assignment and billing, facilitates care coordination among hospital teams, provides medico-legal protection through thorough documentation, and establishes baseline status for tracking clinical progress. Ideal for academic medical centers, community hospitals, hospitalist programs, and teaching services, this template supports quality inpatient care and reduces documentation burden for admitting providers.