Набір клінічної документації

History and physical note: chief complaint, OLDCARTS HPI, histories, review of systems, exam by system, differential, plan

Problem-oriented SOAP note: subjective, objective, numbered problem assessment, plan per problem, follow-up and safety-netting

Daily progress note: interval history, vitals with trend, exam, results, assessment and plan by problem, signature

Operation or procedure note: details, team, findings, steps, specimens and implants, complications, prophylaxis, postoperative orders, checklist

SBAR and ISBAR clinical handoff: identify, situation, background, assessment, request with time frame, closed-loop read-back, outcome

Shift handover by I-PASS: unit overview, illness severity, patient summary, action list, contingencies, receiver synthesis, completion checks

Referral letter: referrer and recipient, urgency, question for specialist, history, medications, investigations, attachments

Admission, transfer and discharge med rec: patient alerts, sources, best possible medication history, comparison with orders, discrepancy types and resolution

Hospital discharge summary: diagnoses, course, alerts and safeguarding, devices, legal and capacity, medication reconciliation, risks and VTE plan, follow-up, pending results

Nursing care plan by the nursing process: assessment, diagnoses (problem, etiology, signs), SMART goals, interventions, evaluation

Case report by CARE topics: de-identified patient information, timeline, diagnostic reasoning, outcomes, patient perspective, consent