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An admission note is a medical record documenting the patient's status, reasons for admission, and initial care instructions. It may include sections on chief complaint, history, physical exam, labs, assessment and plan, and more.
SOAP note is an acronym for subjective, objective, assessment, and plan, a format used by healthcare providers to write notes in a patient's chart. It originated from the problem-oriented medical record and serves as a communication tool and a cognitive framework for physicians.
Inpatient care is the care of patients whose condition requires admission to a hospital. Learn about the history, progress, planning and costs of inpatient care, as well as the concept of hospitalist medicine and the difference between inpatient and outpatient care.
Ambulatory care is medical care provided on an outpatient basis, including diagnosis, treatment, and rehabilitation services. It can be delivered in various settings, such as doctor's offices, clinics, hospitals, or telemedicine, and can prevent or reduce hospital admissions for some conditions.
Learn about the concept, purpose, content and format of nursing documentation, the record of nursing care that is planned and delivered to individual clients. Compare paper-based and electronic nursing documentation systems and their benefits and challenges.
Perioperative is the period of a patient's surgical procedure, including ward admission, anesthesia, surgery, and recovery. Learn about the three phases of perioperative care (preoperative, intraoperative, and postoperative) and their goals, activities, and challenges.
A medical procedure is a course of action intended to achieve a result in the delivery of healthcare. This article lists various kinds of medical procedures, such as diagnostic, therapeutic, surgical, and anesthetic, with definitions and examples.
C-CDA is a markup standard that provides a library of CDA formatted documents for electronic health records. It is used for exchanging clinical information in the US and internationally, and includes 11 document types such as Care Plan, Consultation Note, and Discharge Summary.