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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. [1]
The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.
It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]
When Courtney Baker's baby was diagnosed with Down syndrome her doctor advised her to get an abortion -- and now she's opening up about the experience. Mom writes letter to doctor: 'You were wrong ...
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The initial diagnostic impression can be a broad term describing a category of diseases instead of a specific disease or condition. After the initial diagnostic impression, the clinician obtains follow up tests and procedures to get more data to support or reject the original diagnosis and will attempt to narrow it down to a more specific level.
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“No. I just woke up in the hospital and then they brought me over here.” “You’re lucky. Usually they’d put you in the tower. It’s awful up there—like you’re stuck in somebody’s bad dream. I was up there once for a week before they even knew who my psychiatrist was. They give you your meds and forget about you.