Search results
Results from the WOW.Com Content Network
An admission form is a fundamental record in nursing documentation. It documents a client's status, reasons why the client is being admitted, and the initial instructions for that client's care. [3] The form is completed by a nurse when a client is admitted to a health care facility.
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.
Under Canadian federal law, the patient owns the information contained in a medical record, but the healthcare provider owns the records themselves. [29] The same is true for both nursing home and dental records. In cases where the provider is an employee of a clinic or hospital, it is the employer that has ownership of the records.
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]
Point of care (POC) documentation is the ability for clinicians to document clinical information while interacting with and delivering care to patients. [10] The increased adoption of electronic health records (EHR) in healthcare institutions and practices creates the need for electronic POC documentation through the use of various medical devices. [11]
A typical assessment and treatment space for patients in an ambulatory care clinic. Sites where ambulatory care can be delivered include: Doctor's surgeries/Doctor's offices/General medical practice: This is the most common site for the delivery of ambulatory care in many countries, and usually consists of a physician's visit.
Nursing Practice Applications: [34] Capture patient care data using a standardized coded nursing terminology. Code electronic clinical encounters: diagnoses, interventions, and outcomes. Track nurses' contribution to patient care and care outcomes. Provide standardized concepts (data/elements) for clinical pathways and decision support.
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).