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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.
APACHE II ("Acute Physiology and Chronic Health Evaluation II") is a severity-of-disease classification system, [1] one of several ICU scoring systems.It is applied within 24 hours of admission of a patient to an intensive care unit (ICU): an integer score from 0 to 71 is computed based on several measurements; higher scores correspond to more severe disease and a higher risk of death.
Patients are admitted to the intensive care unit if their medical needs are greater than what the general hospital ward can provide. Indications for the ICU include blood pressure support for cardiovascular instability ( hypertension / hypotension ), sepsis , post-cardiac arrest syndrome or certain cardiac arrhythmias . [ 4 ]
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]
Progress Note - This template represents a patient's clinical status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare encounter. [ 14 ] Transfer Summary - The Transfer Summary standardizes critical information for exchange of information between providers of care when a patient moves between ...
Intensive care unit ICU patients often require mechanical ventilation if they have lost the ability to breathe normally.. An intensive care unit (ICU), also known as an intensive therapy unit or intensive treatment unit (ITU) or critical care unit (CCU), is a special department of a hospital or health care facility that provides intensive care medicine.
A wide range of terms may be used to describe a patient's condition in the United States. The American Hospital Association advises physicians to use the following one-word conditions in describing a patient's condition to those inquiring, including the media. [2] Undetermined Patient awaiting physician and/or assessment. Good
.doc (an abbreviation of "document") is a filename extension used for word processing documents stored on Microsoft's proprietary Microsoft Word Binary File Format; it was the primary format for Microsoft Word until the 2007 version replaced it with Office Open XML.docx files. [4] Microsoft has used the extension since 1983.