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Discharge Summary - The Discharge Summary is a document which synopsizes a patient's admission to a hospital, LTPAC provider, or other setting. It provides information for the continuation of care following discharge. [10]
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]
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]
Aldrete's scoring system is a commonly used scale for determining when postsurgical patients can be safely discharged from the post-anesthesia care unit (PACU), generally to a second stage (phase II) recovery area, hospital ward, or home.
Opioid-Related Hospital Use, National and State. This topic reports population-based rates of opioid-related hospital use by discharge quarter. Trends are available for inpatient stays and emergency department visits by expected payer. Neonatal Abstinence Syndrome (NAS), National and State. This new topic provides trends in NAS-related newborn ...
The only currently nationally endorsed measure of transitional care quality is the Care Transitions Measure (CTM), which is a 15-item survey for administration to patients after discharge from the hospital. [6] The measure also exists as a 3-item survey. Patient responses to the survey predicts return to the emergency department and/or hospital ...
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The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.