Admission note

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Admission Note

An Admission Note (pronunciation: ad-mish-un noht) is a document or digital record that is part of a patient's medical record. It is created by a healthcare provider when a patient is admitted to a hospital or other healthcare facility.

Etymology

The term "Admission Note" is derived from the English words "admission," meaning the act of admitting or allowing to enter, and "note," meaning a brief record of something written down to assist the memory or for future reference.

Definition

An Admission Note is a detailed account of a patient's current condition, history of present illness, past medical history, family history, social history, review of systems, physical examination findings, results of investigations, problem list, assessment, and plan. It is written by the admitting physician or nurse practitioner at the time of patient admission to a healthcare facility.

Related Terms

  • Medical History: A record of information about a person's health, including past illnesses, surgeries, and treatments.
  • Physical Examination: A routine test a doctor or nurse performs to check a person's general health.
  • Healthcare Provider: A person or organization that provides medical services.
  • Hospital: A health care institution providing patient treatment with specialized medical and nursing staff and medical equipment.
  • Nurse Practitioner: A nurse who has completed advanced training and can perform many of the same functions as a doctor.
  • Physician: A professional who practices medicine, which is concerned with promoting, maintaining, or restoring health through the study, diagnosis, prognosis and treatment of disease, injury, and other physical and mental impairments.

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