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It is sometimes also referred to as reason for encounter (RFE), presenting problem, problem on admission or reason for presenting. [citation needed] [1] The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other reason for a medical encounter. [2]
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.
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.
The admitting staff discuss the reasons for admission with the patient and their "care partners" and what health criteria are required for the patient's discharge. "Care partners" are then intricately involved with the patient's care by their entire attending healthcare team, including physicians, nurses, nutritionists, social workers, and more.
Partner services is a public health term which refers to the health intervention given to a client's intimate partners when a client goes to a health care provider requesting health care. Partner notification is a type of partner service, wherein if someone has a contagious disease , the health care provider finding the problem will try to ...
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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A medical diagnosis for the purpose of the medical visit on the given date of the note written is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely. The assessment will also include possible and likely etiologies of ...