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  2. Inpatient care - Wikipedia

    en.wikipedia.org/wiki/Inpatient_care

    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.

  3. Admission note - Wikipedia

    en.wikipedia.org/wiki/Admission_note

    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.

  4. Patient - Wikipedia

    en.wikipedia.org/wiki/Patient

    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 assessment takes place after the patient has gone home. [2]

  5. Consolidated Clinical Document Architecture - Wikipedia

    en.wikipedia.org/wiki/Consolidated_Clinical...

    It provides information for the continuation of care following discharge. [10] History and Physical - A History and Physical (H&P) note is a medical report that documents the current and past conditions of the patient. [11] Operative Note - The Operative Note is created immediately following a surgical or other high-risk procedure.

  6. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, X-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health ...

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    Image source: The Motley Fool. HCA Healthcare (NYSE: HCA) Q4 2024 Earnings Call Jan 24, 2025, 10:00 a.m. ET. Contents: Prepared Remarks. Questions and Answers. Call ...

  8. Electronic health record - Wikipedia

    en.wikipedia.org/wiki/Electronic_health_record

    This can include discharge/transfer orders, pharmacy orders, radiology results, laboratory results and any other data from ancillary services or provider notes. [65] This type of event monitoring has been implemented using the Louisiana Public health information exchange linking statewide public health with electronic medical records.

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