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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]
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]
Archived from the original (PDF) on 7 September 2012. "LCP information leaflet for healthcare professionals" (PDF). Liverpool Care Pathway. Archived from the original (PDF) on 7 September 2012. "LCP standard template, for use in a hospital" (PDF). Liverpool Care Pathway. December 2009. Archived from the original (PDF) on 3 July 2012.
The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care.
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The NHS was established within the differing nations of the United Kingdom through differing legislation, and as such there has never been a singular British healthcare system, instead there are 4 health services in the United Kingdom; NHS England, the NHS Scotland, HSC Northern Ireland and NHS Wales, which were run by the respective UK government ministries for each home nation before falling ...
CMS defines a hospital readmission as "an admission to an acute care hospital within 30 days of discharge from the same or another acute care hospital. [1]" It uses an "all-cause" definition, meaning that the cause of the readmission does not need to be related to the cause of the initial hospitalization.
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