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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]
CMS defines a hospital readmission as "an admission to an acute care hospital within 30 days of discharge from the same or another acute care hospital. [1]" It uses an "all-cause" definition, meaning that the cause of the readmission does not need to be related to the cause of the initial hospitalization.
A Clinical Data Repository could be used in the hospital setting to track prescribing trends as well as for the monitoring of infectious diseases. One area CDR's could potentially be used is monitoring the prescribing of antibiotics in hospitals especially as the number of antibiotic-resistant bacteria is ever increasing.
The HL7 Consolidated Clinical Document Architecture (C-CDA) is an XML-based markup standard which provides a library of CDA formatted documents. Clinical documents using the C-CDA standards are exchanged billions of times annually in the United States.
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, discharge, and transfer (ADT) system is a backbone system for the structure of other types of business systems. An ADT system is one of four types of core business systems: ADT, financial, scheduling, and acuity (McGonigle, D., & Mastrain, K., 2012).