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Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization. Progress notes serve as a record of events during a patient's care, allow clinicians to compare past status to current status, serve to communicate findings, opinions and plans between physicians and other ...
Nursing documentation mainly consists of a client's background information or nursing history referred as admission form, numerous assessment forms, nursing care plan and progress notes. These documents record the client's data captured at the relevant stages of the nursing process . [ 2 ]
This is an accepted version of this page This is the latest accepted revision, reviewed on 11 February 2025. Long-term brain disorders causing impaired memory, thinking and behavior This article is about the cognitive disorder. For other uses, see Dementia (disambiguation). "Senile" and "Demented" redirect here. For other uses, see Senile (disambiguation) and Demented (disambiguation). Medical ...
This is a list of mnemonics used in medicine and medical science, categorized and alphabetized. A mnemonic is any technique that assists the human memory with information retention or retrieval by making abstract or impersonal information more accessible and meaningful, and therefore easier to remember; many of them are acronyms or initialisms which reduce a lengthy set of terms to a single ...
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.
Psychomotor agitation is a symptom in various disorders and health conditions. It is characterized by unintentional and purposeless motions and restlessness, often but not always accompanied by emotional distress and is always an indicative for admission.
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A medical diagnosis for the purpose of the medical visit on the given date of the note written is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely. The assessment will also include possible and likely etiologies of ...