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Diagnostic Imaging Report - A Diagnostic Imaging Report (DIR) is a document that contains a consulting specialist's interpretation of image data. [9] Discharge Summary - The Discharge Summary is a document which synopsizes a patient's admission to a hospital, LTPAC provider, or other setting.
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]
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]
Typical data types which are often found within a CDR include: clinical laboratory test results, patient demographics, pharmacy information, radiology reports and images, pathology reports, hospital admission, discharge and transfer dates, ICD-9 codes, discharge summaries, and progress notes. [1]
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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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