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2. Consolidated Clinical Document Architecture - Wikipedia

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

   It provides information for the continuation of care following discharge. [10] History and Physical - A History and Physical (H&P) note is a medical report that documents the current and past conditions of the patient. [11] Operative Note - The Operative Note is created immediately following a surgical or other high-risk procedure.

3. Progress note - Wikipedia

   en.wikipedia.org/wiki/Progress_note

   Physicians are generally required to generate at least one progress note for each patient encounter. Physician documentation is then usually included in the patient's chart and used for medical, legal, and billing purposes. Nurses are required to generate progress notes on a more frequent basis, depending on the level of care and may be ...

4. File:Daniel Reed Honorable Discharge.pdf - Wikipedia

   en.wikipedia.org/wiki/File:Daniel_Reed_Honorable...

   This file contains additional information, probably added from the digital camera or scanner used to create or digitize it. If the file has been modified from its original state, some details may not fully reflect the modified file.

5. Admission note - Wikipedia

   en.wikipedia.org/wiki/Admission_note

   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]

6. Inpatient care - Wikipedia

   en.wikipedia.org/wiki/Inpatient_care

   When considering the patient's current state, although the patient may be eligible for discharge it is important to examine factors such as the likelihood of re-injury to avoid higher health care costs. Patients' homes should also be visited and examined before they are discharged from the hospital to determine any immediate challenges and ...

7. Medical record - Wikipedia

   en.wikipedia.org/wiki/Medical_record

   Within the medical record, individual medical encounters are marked by discrete summations of a patient's medical history by a physician, nurse practitioner, or physician assistant and can take several forms. Hospital admission documentation (i.e., when a patient requires hospitalization) or consultation by a specialist often take an exhaustive ...