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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]
Physicians are generally required to generate at least one progress note for each patient encounter. Physician documentation is then usually included in the patient's chart and used for medical, legal, and billing purposes. Nurses are required to generate progress notes on a more frequent basis, depending on the level of care and may be ...
The electronic health record (EHR) is a more longitudinal collection of the electronic health information of individual patients or populations. The EMR, in contrast, is the patient record created by providers for specific encounters in hospitals and ambulatory environments and can serve as a data source for an EHR. [6] [7]
Clinical user profiles – Tools used to personalize and/or gather information about clinical users [1] Clinical templates – Documents used to standardize and expedite the development of a clinical document; Clinical staff education modules – Documents used to educate a staff member about a common clinical subject
A kardex (plural kardexes) is a genericised trademark for a medication administration record. [2] The term is common in Ireland and the United Kingdom.In the Philippines, the term is used to refer the old census charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...
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Physician to nurse communication can worsen if each group works alone at their workstations. But, in general, the options to reuse order sets anew with new patients lays the basic for substantial enhancement of the processing of services to the patients in the complex distribution of work amongst the roles involved.
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