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Hospital Admission
An admission note is part of a medical record that documents the patient's medical state, status (including medical history, history and physical examination, 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. Purpose Admission notes document the reasons why a patient is being admitted for inpatient care to a hospital or other facility, the patient's baseline status, and the initial instructions for that patient's care. Health care professionals use them to record a patient's baseline status and may write additional on-service notes, progress notes (SOAP notes), preoperative notes, operative notes, postoperative notes, procedure notes, delivery notes, postpartum notes, and discharge notes. These notes constitute a large part of the medical record. Medical students often develop their clinical reasoning skills by writing admission notes. The traditional, ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Medical Record
The terms medical record, health record and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and health care, care across time within one particular health care provider's jurisdiction. A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, X-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health care providers and is generally enforced as a licensing or certification prerequisite. The terms are used for the written (paper notes), physical (image films) and digital records that exist for each individual patient and for the body of information found therein. Medical records have traditionally been compiled and maintained by health care providers, but advances in online data sto ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
History Of Present Illness
Following the chief complaint in medical history taking, a history of the present illness (abbreviated HPI) (termed history of presenting complaint (HPC) in the UK) refers to a detailed interview prompted by the chief complaint or presenting symptom (for example, pain). Questions to include Different sources include different questions to be asked while conducting an HPI. Several acronyms have been developed to categorize the appropriate questions to include. The Centers for Medicare and Medicaid Services has published criteria for what constitutes a reimbursable HPI. A "brief HPI" constitutes one to three of these elements. An "extended HPI" includes four or more of these elements. Also usable is SOCRATES. For chronic pain, the Stanford Five may be assessed to understand the pain experience from the patient's primary belief system. See also * Medical record * Medical history The medical history, case history, or anamnesis (from Greek: ἀνά, ''aná'', "open", and μν ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Childbirth
Childbirth, also known as labour, parturition and delivery, is the completion of pregnancy, where one or more Fetus, fetuses exits the Womb, internal environment of the mother via vaginal delivery or caesarean section and becomes a newborn to the world. In 2019, there were about 140.11 million human births globally. In Developed country, developed countries, most deliveries occur in hospitals, while in Developing country, developing countries most are home births. The most common childbirth method worldwide is vaginal delivery. It involves four stages of labour: the cervical effacement, shortening and Cervical dilation, opening of the cervix during the first stage, descent and birth of the baby during the second, the delivery of the placenta during the third, and the recovery of the mother and infant during the fourth stage, which is referred to as the Postpartum period, postpartum. The first stage is characterised by abdominal cramping or also back pain in the case of B ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Past Surgical History
The medical history, case history, or anamnesis (from Greek: ἀνά, ''aná'', "open", and μνήσις, ''mnesis'', "memory") of a patient is a set of information the physicians collect over medical interviews. It involves the patient, and eventually people close to them, so to collect reliable/objective information for managing the medical diagnosis and proposing efficient medical treatments. The medically relevant complaints reported by the patient or others familiar with the patient are referred to as symptoms, in contrast with clinical signs, which are ascertained by direct examination on the part of medical personnel. Most health encounters will result in some form of history being taken. Medical histories vary in their depth and focus. For example, an ambulance paramedic would typically limit their history to important details, such as name, history of presenting complaint, allergies, etc. In contrast, a psychiatric history is frequently lengthy and in depth, as many deta ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Atopic
Atopy is the tendency to produce an exaggerated immunoglobulin E (IgE) immune response to otherwise harmless substances in the environment. Allergic diseases are clinical manifestations of such inappropriate, atopic responses. Atopy may have a hereditary component, although contact with the allergen or irritant must occur before the hypersensitivity reaction can develop (characteristically after re-exposure). Maternal psychological trauma during pregnancy may also be a strong indicator for development of atopy. The term ''atopy'' was coined by Arthur F. Coca and Robert Cooke in 1923 from the Greek ἀτοπία meaning "the state of being out of place", "absurdity". Many physicians and scientists use the term ''atopy'' for any reaction mediated by IgE (even those that are appropriate and proportional to the antigen), but many pediatricians reserve it to refer only to a genetically mediated predisposition to an excessive IgE reaction. Signs and symptoms Atopic sensitization ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Asthma
Asthma is a common long-term inflammatory disease of the airways of the lungs. It is characterized by variable and recurring symptoms, reversible airflow obstruction, and easily triggered bronchospasms. Symptoms include episodes of wheezing, coughing, chest tightness, and shortness of breath. A sudden worsening of asthma symptoms sometimes called an 'asthma attack' or an 'asthma exacerbation' can occur when allergens, pollen, dust, or other particles, are inhaled into the lungs, causing the bronchioles to constrict and produce mucus, which then restricts oxygen flow to the alveoli. These may occur a few times a day or a few times per week. Depending on the person, asthma symptoms may become worse at night or with exercise. Asthma is thought to be caused by a combination of genetic and environmental factors. Environmental factors include exposure to air pollution and allergens. Other potential triggers include medications such as aspirin and beta blockers. Diag ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Past Medical History
In a medical encounter, a past medical history (abbreviated PMH) is the total sum of a patient's health status prior to the presenting problem. Questions to include Different sources include different questions to be asked while conducting a PMH, but in general, they include the following: * General state of health: e.g. excellent, good, fair, poor. Note any significant change from previous state. * Past illnesses: e.g. cancer, heart disease, hypertension, diabetes. * Hospitalizations: including all medical, surgical, and psychiatric hospitalizations. Note the date, reason, duration for the hospitalization. * Injuries, or accidents: note the type and date of injury. * Surgeries: note the type of procedure, date, hospital, surgeon, and any complications. * Current medications: note name, dosage, frequency of any medication, including any over-the-counter medications and herbal remedies. Note whether patient is taking the medications according to the prescribed instructions. * ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Medications
Medication (also called medicament, medicine, pharmaceutical drug, medicinal product, medicinal drug or simply drug) is a drug used to medical diagnosis, diagnose, cure, treat, or preventive medicine, prevent disease. Drug therapy (pharmacotherapy) is an important part of the medicine, medical field and relies on the science of pharmacology for continual advancement and on pharmacy for appropriate management. Drugs are Drug class, classified in many ways. One of the key divisions is by level of controlled substance, control, which distinguishes prescription drugs (those that a pharmacist dispenses only on the medical prescription) from over-the-counter drugs (those that consumers can order for themselves). Medicines may be classified by mode of action, route of administration, biological system affected, or therapeutic effects. The World Health Organization keeps a list of essential medicines. Drug discovery and drug development are complex and expensive endeavors undertake ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Allergies
Allergies, also known as allergic diseases, are various conditions caused by hypersensitivity of the immune system to typically harmless substances in the environment. These diseases include Allergic rhinitis, hay fever, Food allergy, food allergies, atopic dermatitis, allergic asthma, and anaphylaxis. Symptoms may include allergic conjunctivitis, red eyes, an itchy rash, sneeze, sneezing, coughing, a rhinorrhea, runny nose, shortness of breath, or swelling. Note that food intolerances and food poisoning are separate conditions. Common allergens include pollen and certain foods. Metals and other substances may also cause such problems. Food, insect stings, and medications are common causes of severe reactions. Their development is due to both genetic and environmental factors. The underlying mechanism involves immunoglobulin E antibodies (IgE), part of the body's immune system, binding to an allergen and then to FcεRI, a receptor on mast cells or basophils where it triggers ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Electronic Medical Records
An electronic health record (EHR) is the systematized collection of electronically stored patient and population health information in a digital format. These records can be shared across different health care settings. Records are shared through network-connected, enterprise-wide information systems or other information networks and exchanges. EHRs may include a range of data, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal statistics like age and weight, and billing information. For several decades, EHRs have been touted as key to increasing quality of care. EHR combines all patients' demographics into a large pool, which assists providers in the creation of "new treatments or innovation in healthcare delivery" to improve quality outcomes in healthcare. Combining multiple types of clinical data from the system's health records has helped clinicians identify and stratify c ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Review Of Systems
A review of systems (ROS), also called a systems enquiry or systems review, is a technique used by healthcare providers for eliciting a medical history from a patient. It is often structured as a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient (as opposed to the objective signs perceived by the clinician). Along with the physical examination, it can be particularly useful in identifying conditions that do not have precise diagnostic tests. Examples Whatever system a specific condition may seem restricted to, it may be reasonable to review all the other systems in a comprehensive history. Different sources describe slightly different systems of organizing the organ systems. However, the following are examples of what can be included. Unspecified and other symptoms can't consider for both HPI and ROS: There are 14 systems recognized by the Centers for Medicare and Medicaid Services The Centers for Med ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
OPQRST
__NOTOC__OPQRST is a mnemonic initialism used by medical professionals to accurately discern reasons for a patient's symptoms and history in the event of an acute illness. It is specifically adapted to elicit symptoms of a possible heart attack. Each letter stands for an important line of questioning for the patient assessment. This is usually taken along with vital signs and the SAMPLE history and would usually be recorded by the person delivering the aid, such as in the "Subjective" portion of a SOAP note, for later reference. "PQRST" (onset "O") is sometimes used in conjunction. The term "OPQRST-AAA" adds "aggravating/alleviating factors", "associated symptoms", and "attributions/adaptations". Use The parts of the mnemonic are: ;Onset of the event :What the patient was doing when it started (active, inactive, stressed, etc.), whether the patient believes that activity prompted the pain, and whether the onset was sudden, gradual or part of an ongoing chronic problem. ;Prov ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
