Decision Status: Completed
Admission to a hospital is a well-defined, high-volume activity that needs documentation.
The word "Admission" can also be used to refer to entering a health system service, though not as commonly.
How do we define and classify an Admission document?
Keeping the type of service of 'admission' only for use with hospital admission seems too narrow at first, but no other health system service has as high a standard for the detail and breadth of evaluation that goes into a hospital admission evaluation. So the service is unique, has medical-legal significance, and very high volume; it deserves its own ToS. It will make the document stand out in the list of documents. It can also be used to signify the start of a hospital encounter when encounter data is unavailable. One could argue that pairing Admission with Setting = Hospital can achieve the significance desired, but we choose to keep the significance of the admission process in the single word/conept.
The use of "History and Physical" is a common alternative way of expressing the action and documentation of admitting a patient to a hospital. However, the admission process actually includes Medication reconciliation, Investigations, Assessments, and a Treatment plan in addition to the History and physical. So a broader word was desired. Additionally, the LOINC Sub-Analysis committee was asked what was the preferred ToS and they indicated "Admission Evaluation".
The narrow use of the word 'admission' excludes it from other health services, so they will have to find other words to describe the documentation of the evaluation before starting the service.
Use of SMD with 'Admission' is not as common as one would expect; it is commonly referred to as 'the admission' document, as they are very similar regardless of who writes it. Indicating SMD is good to specify in the document type if it is an admission directly to a specialty service.
It is assumed the admission is done by a person with role of physician so it does not need to be specified. However, other roles certainly can be specified.
Setting is suppressed unless it is LTC or another location that is required to have an admission process similar to a hospital in comprehensiveness.
The action of admitting someone to the hospital is captured in the ToS = Admission Evaluation.
SMD can be used.
Role is only used for non-physicians
Setting is suppressed or can be "LTC"
MB:5
IB:3
NS:5
ML:5
IBe:5
MK: 5
The action of admitting someone to the hospital is captured in the ToS = Admission Evaluation.
SMD can be used.
Role is only used for non-physicians
Setting is suppressed or can be "LTC"