Which document is written or dictated by the admitting physician and includes the patient's history, exam results, initial diagnoses, and plan of treatment?

Which document is written or dictated by the admitting physician and includes the patient's history, exam results, initial diagnoses, and plan of treatment?

• A. Admission Summary
• B. History and Physical
• C. Nurse's Notes
• D. Physician's Progress Notes

Answer: (B)

The document created by the admitting physician that captures the patient’s history, exam findings, initial diagnoses, and plan of treatment is the History and Physical. This entry is written or dictated at admission and sets the baseline for the patient’s condition and the initial care plan. Other documents serve different purposes: an admission summary is a later, concise recap of the hospitalization; nurse’s notes record nursing observations and care; and physician’s progress notes detail ongoing status and updates after admission.

The document created by the admitting physician that captures the patient’s history, exam findings, initial diagnoses, and plan of treatment is the History and Physical. This entry is written or dictated at admission and sets the baseline for the patient’s condition and the initial care plan. Other documents serve different purposes: an admission summary is a later, concise recap of the hospitalization; nurse’s notes record nursing observations and care; and physician’s progress notes detail ongoing status and updates after admission.