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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.
The PAS records the patient's demographics (e.g. name, home address, date of birth) and details all patient contact with the hospital, both outpatient and inpatient. [ 1 ] PAS systems are often criticised for providing only administrative functionality to hospitals, however attempts to provide more clinical and operational functionality have ...
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]
An admission, discharge, and transfer (ADT) system is a backbone system for the structure of other types of business systems. An ADT system is one of four types of core business systems: ADT, financial, scheduling, and acuity (McGonigle, D., & Mastrain, K., 2012).
A hospital information system (HIS) is an element of health informatics that focuses mainly on the administrational needs of hospitals.In many implementations, a HIS is a comprehensive, integrated information system designed to manage all the aspects of a hospital's operation, such as medical, administrative, financial, and legal issues and the corresponding processing of services.
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Health information management's standards history is dated back to the introduction of the American Health Information Management Association, founded in 1928 "when the American College of Surgeons established the Association of Record Librarians of North America (ARLNA) to 'elevate the standards of clinical records in hospitals and other medical institutions.'" [3]
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