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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]
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.
The standardized format for the history starts with the chief concern (why is the patient in the clinic or hospital?) followed by the history of present illness (to characterize the nature of the symptom(s) or concern(s)), the past medical history, the past surgical history, the family history, the social history, their medications, their ...
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]
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Microsoft Word is a word processing program developed by Microsoft.It was first released on October 25, 1983, [11] under the name Multi-Tool Word for Xenix systems. [12] [13] [14] Subsequent versions were later written for several other platforms including: IBM PCs running DOS (1983), Apple Macintosh running the Classic Mac OS (1985), AT&T UNIX PC (1985), Atari ST (1988), OS/2 (1989 ...
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