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  2. Clinical Document Architecture - Wikipedia

    en.wikipedia.org/wiki/Clinical_Document_Architecture

    Discharge summary (following inpatient care) History & physical; Specialist reports, such as those for medical imaging or pathology; An XML element in a CDA supports unstructured text, as well as links to composite documents encoded in pdf, docx, or rtf, as well as image formats like jpg and png. [3]

  3. 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.

  4. 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. [1]

  5. Continuity of Care Document - Wikipedia

    en.wikipedia.org/wiki/Continuity_of_Care_Document

    The patient summary contains a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to ...

  6. File:PSRO hospital discharge data set (PHDDS) - trainee ...

    en.wikipedia.org/wiki/File:PSRO_hospital...

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  8. File:Uniform hospital discharge data - minimum data set (IA ...

    en.wikipedia.org/wiki/File:Uniform_hospital...

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  9. 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. [1]

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