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  2. Consolidated Clinical Document Architecture - Wikipedia

    en.wikipedia.org/wiki/Consolidated_Clinical...

    Discharge Summary - The Discharge Summary is a document which synopsizes a patient's admission to a hospital, LTPAC provider, or other setting. It provides information for the continuation of care following discharge. [10]

  3. Admission note - Wikipedia

    en.wikipedia.org/wiki/Admission_note

    Health care professionals use them to record a patient's baseline status and may write additional on-service notes, progress notes , preoperative notes, operative notes, postoperative notes, procedure notes, delivery notes, postpartum notes, and discharge notes. These notes constitute a large part of the medical record.

  4. Continuity of Care Document - Wikipedia

    en.wikipedia.org/wiki/Continuity_of_Care_Document

    The patient summary contains a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to ...

  5. Progress note - Wikipedia

    en.wikipedia.org/wiki/Progress_note

    Another example is the DART system, organized into Description, Assessment, Response, and Treatment. [2] Documentation of care and treatment is an extremely important part of the treatment process. Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization.

  6. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    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.

  7. Inpatient care - Wikipedia

    en.wikipedia.org/wiki/Inpatient_care

    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.

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  9. Home health nursing - Wikipedia

    en.wikipedia.org/wiki/Home_health_nursing

    Home health is a nursing specialty in which nurses provide multidimensional [1] home care to patients of all ages. Home health care is a cost efficient way to deliver quality care in the convenience of the client's home. [2] Home health nurses create care plans to achieve goals based on the client's diagnosis.

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