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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.
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]
The PAS records the patient's demographics (e.g. name, home address, date of birth) and details all patient contact with the hospital, both outpatient and inpatient. [ 1 ] PAS systems are often criticised for providing only administrative functionality to hospitals, however attempts to provide more clinical and operational functionality have ...
Outpatient department of a hospital provides diagnosis and care for patients that do not need to stay overnight. [1] The departments are also sometimes called outpatient clinics, but are distinct from clinics independent of hospitals, almost all of which are designed mostly or exclusively for outpatient care and may be also be called outpatient clinics.
An admission, discharge, and transfer (ADT) system is a backbone system for the structure of other types of business systems. An ADT system is one of four types of core business systems: ADT, financial, scheduling, and acuity (McGonigle, D., & Mastrain, K., 2012).
The patient health record is the primary legal record documenting the health care services provided to a person in any aspect of the health care system. The term includes routine clinical or office records, records of care in any health related setting, preventive care, lifestyle evaluation, research protocols and various clinical databases.
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A kardex (plural kardexes) is a genericised trademark for a medication administration record. [2] The term is common in Ireland and the United Kingdom.In the Philippines, the term is used to refer the old census charts of the charge nurse usually used during endorsement, in which index cards are used, but has been gradually been replaced by modern health data systems and pre-printed charts and ...
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