Admission note definition

Admission note means a dated notation that is written by a professional member of the health team after the initial assessment of a patient and that documents the relevant diagnoses; the patient’s health history; environmental, safety, and social factors of the patient’s home; the patient’s nutritional requirements, medications, and treatments; and the patient’s physical and mental levels of functioning.

Examples of Admission note in a sentence

• The fellow or APP is to complete a CCM Attending/Fellow Admission note on all new admissions or transfers to the PICU.

• Provider must upload and attach to the electronic PA Adjustment Request one of the following:(1) Discharge summary from the facility; or(2) Admission note from facility.

• Admission note from facility.• Disability Determination for Mental Health Reasons -An adult has been determined disabled by the Social Security Administration because of a mental health disorder.

• Admission note and/or discharge summary if there has been an inpatient mental health admission within the past year*If there is an evaluation but it is older than one year, it can be submitted along with a recent progress note or treatment plan.

• Comprehensive H&P OR Admission note OR Behavioral health paper – refer to SCPE-specific syllabi for requirements.

• Admission note from facility. Disability Determination for Mental Health Reasons -An adult has been determined disabled by the Social Security Administration because of a mental health disorder.

• The paediatrician involved in the care of Baby B stated that the paediatric house surgeon was present at the delivery and noted that Baby B passed meconium around the time of delivery, and the presence of meconium “behind baby” on delivery was documented in the NICU17 Retrieval — Admission note.

• The CAP referral package must include copies of the following: • Intake note by physician• Psychosocial report (C217A and C217B)• Admission note (C220)• Nursing Admission Assessment (C530Y)• Physical exam (C225H)• Psychological testing (if completed)• All lab results• EKG (if requested)• Discharge order from (C290B0) On the date of the scheduled appointment the resident fellow or psychology intern is to document on a Progress note (C255).

• Admission note and ongoing daily notes shall demonstrate medical necessity for acute and administrative inpatient care.

• The Hospice chart must include: o Admit order stating the following “admit to general inpatient hospice care” o Admission note within 24 hours by attending physician o A notation by attending indicating that the H&P has been reviewed and updated if necessary o Nursing database must be updated by RN within 24 hours o Final progress note must be written by attending, even though pronouncement of death may be done by other clinician.