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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.
Within the medical record, individual medical encounters are marked by discrete summations of a patient's medical history by a physician, nurse practitioner, or physician assistant and can take several forms. Hospital admission documentation (i.e., when a patient requires hospitalization) or consultation by a specialist often take an exhaustive ...
Inpatient care is the care of patients whose condition requires admission to a hospital. Progress in modern medicine and the advent of comprehensive out-patient clinics ensure that patients are only admitted to a hospital when they are extremely ill or have severe physical trauma. [1]
The admission to the hospital involves the production of an admission note. The leaving of the hospital is officially termed discharge, and involves a corresponding discharge note, and sometimes an assessment process to consider ongoing needs. In the English National Health Service this may take the form of "Discharge to Assess" - where the ...
An admitting privilege is the right of a doctor to admit patients to a hospital for medical treatment without first having to go through an emergency department.This is generally restricted to doctors on the hospital staff, although in some countries such as Canada and the United States, both general practitioners and specialists can have admitting privileges.
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postadmission day (e.g. PAD 6 equals the sixth day of being in hospital) peripheral airspace disease Passively Acquired anti-D PAF: platelet-activating factor paroxysmal atrial fibrillation (meaning intermittent AF) PAH: pulmonary arterial hypertension phenylalanine hydroxylase PAI-1: plasminogen activator inhibitor-1: PAL: posterior axillary ...
While not all admissions for these conditions are avoidable, appropriate ambulatory care could help prevent their onset, control an acute episode, or manage a chronic disease or condition. [6] [24] [25] For Medicaid-covered and uninsured U.S. hospital stays in 2012, six of the top ten diagnoses were ambulatory care sensitive conditions. [35]