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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.
Infobox for hospitals, worldwide from large to small. Formats a right-side infobox to display many data items about a hospital, with the typical labels listed down the left side, and the corresponding data values on the right side of the box. Template parameters This template prefers block formatting of parameters. Parameter Description Type Status Name name Name The hospital name. When not ...
This procedure is in addition to written records of the patient's personal and medical details and any treatment or medication applied prior to transport to the hospital. The word is treated as a noun by personnel (whether first aiders, community first responders or paramedics) who might refer to e.g. 'passing an ASHICE'.
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]
Hospital emergency codes are coded messages often announced over a public address system of a hospital to alert staff to various classes of on-site emergencies. The use of codes is intended to convey essential information quickly and with minimal misunderstanding to staff while preventing stress and panic among visitors to the hospital.
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