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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]
It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]
In United States and Canada, an attending physician (also known as a staff physician or supervising physician) is a physician (usually an M.D., or D.O. or D.P.M. in the United States) who has completed residency and practices medicine in a clinic or hospital, in the specialty learned during residency. [1]
When Courtney Baker's baby was diagnosed with Down syndrome her doctor advised her to get an abortion -- and now she's opening up about the experience. Mom writes letter to doctor: 'You were wrong ...
Whiteside knew that people who leave the hospital after a suicide attempt are at a greater risk of harming themselves again within 90 days. And yet the doctors at Harborview were only providing referrals for clinics most patients would never visit or putting patients on waiting lists for therapists who might not be right for them.
The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.
Computerized physician order entry (CPOE), sometimes referred to as computerized provider order entry or computerized provider order management (CPOM), is a process of electronic entry of medical practitioner instructions for the treatment of patients (particularly hospitalized patients) under his or her care.
“No. I just woke up in the hospital and then they brought me over here.” “You’re lucky. Usually they’d put you in the tower. It’s awful up there—like you’re stuck in somebody’s bad dream. I was up there once for a week before they even knew who my psychiatrist was. They give you your meds and forget about you.