Can you provide a one-page template for gathering all necessary information for a new internal medicine inpatient admission, including diet orders, deep vein thrombosis (DVT) prophylaxis, code status, advance directive, emergency contact, medication reconciliation, and emergency department (ED) course?

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Last updated: May 3, 2026 • View editorial policy

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Internal Medicine Inpatient Admission Template

Use a standardized admission order set to systematically capture all essential admission information—this approach has been shown to improve DVT prophylaxis rates from 10.9% to 44% and enhance documentation of critical elements like code status from 10.2% to 57.4% 1.

PATIENT IDENTIFICATION & EMERGENCY CONTACTS

  • Full Name, MRN, DOB, Age
  • Emergency Contact: Name, relationship, phone number (primary and alternate)
  • Advance Directive Status: Present/Absent (if present, location in chart)
  • Healthcare Power of Attorney: Name and contact information

CODE STATUS & GOALS OF CARE

  • Code Status: Full Code / DNR / DNR-CC (Comfort Care)
  • POLST/MOLST on file: Yes/No (if yes, verify orders match current wishes)
  • Goals of Care Discussion: Documented? Date of last discussion?
  • Intubation Status: Full / Limited / None

Note: ED physicians report POLST (86% find very/extremely useful) and code status orders (90% useful) as most critical ACP documents, yet only 31% feel confident finding this information in the EMR 2. Ensure this information is prominently displayed on the main screen of your documentation.

EMERGENCY DEPARTMENT COURSE

  • Chief Complaint & Presenting Symptoms
  • Vital Signs on Arrival: BP, HR, RR, Temp, O2 sat, Pain score
  • ED Interventions: IV fluids (type/volume), medications given, procedures performed
  • Imaging/Labs Completed: Results and interpretation
  • ED Diagnosis & Disposition Reasoning
  • Time Metrics: ED arrival time, time to admission decision

ADMISSION DETAILS

  • Admitting Diagnosis (Primary)
  • Secondary Diagnoses/Comorbidities
  • Admitting Service & Attending Physician
  • Admission Date/Time
  • Expected Length of Stay

MEDICATION RECONCILIATION

  • Home Medications: Name, dose, frequency, last dose taken
  • Allergies: Drug name, reaction type (distinguish true allergy from intolerance)
  • Medications Held on Admission: Reason for holding
  • New Medications Started: Indication for each
  • High-Risk Medications: Anticoagulants, insulin, opioids (verify dosing)

Order sets improve allergy documentation from 9.6% to 54.3% 1.

DVT PROPHYLAXIS

Assess VTE risk and bleeding risk at admission—pharmacological prophylaxis is preferred for acutely ill medical patients unless contraindicated 3.

Risk Stratification:

  • Likely Benefit: Acute medical illness + immobility/reduced mobility
  • Unclear Benefit: Ambulatory, short stay expected
  • Potential Harm: Active bleeding, severe thrombocytopenia, recent neurosurgery

Prophylaxis Orders:

  • Pharmacological (preferred):
    • Enoxaparin 40 mg SC daily (adjust for renal impairment: CrCl <30 use 30 mg daily or UFH)
    • UFH 5000 units SC q8-12h
    • Fondaparinux 2.5 mg SC daily
  • Mechanical (if pharmacological contraindicated):
    • Sequential compression devices (SCDs)
    • Avoid graduated compression stockings alone (insufficient evidence)
  • Duration: Minimum 7 days or until fully ambulatory 3
  • Contraindications Present: Document reason prophylaxis not given

Warning: Order sets can inadvertently increase inappropriate VTEP use in patients with potential harm (58% increase initially) 4. Actively assess contraindications, don't just check a box.

DIET ORDERS

  • Diet Type: Regular / Cardiac / Diabetic / Renal / NPO / Other
  • Texture Modifications: Regular / Mechanical soft / Pureed / Thickened liquids
  • Restrictions: Sodium (2g), fluid restriction (specify mL/day), protein restriction
  • Diabetic Protocol: Carbohydrate-controlled diet + standardized insulin sliding scale 1
  • Aspiration Risk: Swallow evaluation needed? Speech therapy consult?

ACTIVITY & MOBILITY

  • Activity Level: Bedrest / Bedrest with bathroom privileges / Ambulate with assist / Ad lib
  • Fall Risk Assessment: High/Low (if high, implement fall precautions)
  • Physical Therapy Consult: Needed for mobility/deconditioning? 1

MONITORING & DAILY ASSESSMENTS

  • Vital Sign Frequency: Q4h / Q6h / Q shift
  • Telemetry: Yes/No (indication if yes)
  • I/O Monitoring: Strict / Routine
  • Daily Weight: Yes/No
  • Glucose Monitoring: Frequency (if diabetic or on steroids)
  • Oxygen Requirements: Room air / NC / Face mask (specify flow/FiO2)

LINES & DEVICES

  • IV Access: Peripheral / PICC / Central line (document indication and daily necessity assessment)
  • Urinary Catheter: Yes/No (if yes, indication and daily necessity assessment) 5
  • Other Devices: NG tube, chest tube, drains (document indication)

Daily assessment for need of central lines and urinary catheters reduces inappropriate use by 15-16% 5.

CONSULTATIONS & ALLIED HEALTH

  • Specialty Consults Requested: Service, reason, urgency
  • Case Management/Social Work: Discharge planning needs, home services
  • Nutrition: Dietitian consult if indicated
  • Pharmacy: Medication optimization, anticoagulation management
  • Palliative Care: If goals of care discussions needed

Order sets increase allied health consultations from 12.7% to 62.8% 1.

LABORATORY & IMAGING

  • Admission Labs: CBC, CMP, coagulation studies (if relevant)
  • Pending Results: Document what's outstanding
  • Daily Labs Needed: Specify which and frequency
  • Avoid Routine Unnecessary Labs: BUN without indication decreased from 59% to 39.4% with order sets 1

ISOLATION PRECAUTIONS

  • Type: Standard / Contact / Droplet / Airborne / Contact + Droplet
  • Indication: MRSA, C. diff, COVID-19, other

DISCHARGE PLANNING (Day 1)

  • Anticipated Barriers: Transportation, home safety, medication access, follow-up
  • DME Needs: Walker, wheelchair, oxygen, hospital bed
  • Post-Acute Care: Home / Home health / SNF / Rehab facility
  • Follow-Up Appointments: PCP, specialists (arrange before discharge)

DOCUMENTATION EFFICIENCY NOTES

This template format reduces progress note writing time by 3.6 minutes per note and decreases note length by 764-1041 characters while reducing copy-forward text by 22% 6. Structure your daily progress notes similarly for consistency and efficiency.

References

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.