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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]
Though some organizations have their own template for informal report headings, most headings include the date, a name for who the formal report is being addressed to, a name for who the report is from, a subject, a reference, action required, and a distribution list. The Date, To, From, and Subject are all crucial portions of the heading.
Whereas randomized clinical trials usually only inspect one variable or very few variables, rarely reflecting the full picture of a complicated medical situation, the case report can detail many different aspects of the patient's medical situation (e.g. patient history, physical examination, diagnosis, psychosocial aspects, follow up). [8]
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Digital images of the patient, flowsheets from operations/intensive care units, informed consent forms, EKG tracings, outputs from medical devices (such as pacemakers), chemotherapy protocols, and numerous other important pieces of information form part of the record depending on the patient and his or her set of illnesses/treatments.
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A patient agrees to a health intervention based on an understanding of it. The patient has multiple choices and is not compelled to choose a particular one. The consent includes giving permission. These practices are part of what constitutes informed consent, and their history is the history of informed consent.
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