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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]
When a no call, no show is not preventable, such as when an employee suffers a medical emergency and is unable to inform their employer, satisfactory documentation of the situation is expected. In the United States, the Family and Medical Leave Act of 1993 (FMLA) allows employees to take unpaid leave during specifics situations such as medical ...
It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]
When a patient is hospitalized, daily updates are entered into the medical record documenting clinical changes, new information, etc. These often take the form of a SOAP note and are entered by all members of the health-care team (doctors, nurses, physical therapists, dietitians, clinical pharmacists, respiratory therapists , etc.).
The index case or patient zero is the first documented patient in a disease epidemic within a population, [1] or the first documented patient included in an epidemiological study. [2] It can also refer to the first case of a condition or syndrome (not necessarily contagious) to be described in the medical literature, whether or not the patient ...
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