Type of service
- Admission Note - An admission note is a clinical document that provides a clear, comprehensive overview of a patient's condition and care needs at the time of entry into a hospital or inpatient service. It typically includes the reason for admission, presenting symptoms, relevant medical history, physical examination findings, initial diagnostic impressions, and the immediate plan for investigation and treatment. Completed by the admitting physician or other qualified clinician at the start of an inpatient stay, the admission note establishes the baseline clinical picture and supports coordinated, continuous care throughout hospitalization. Although sometimes referred to as an 'Admission H&P', its modern form goes much beyond a history and physical.
- Consultation Note - A consultation note is a clinical document that provides a comprehensive account of a provider's assessment in response to a referral from another health care provider. It typically includes the reason for referral, relevant history, examination findings, investigations reviewed or ordered, the consultant's clinical impression, and recommendations for diagnosis, treatment, or ongoing management. It is typically completed by an RCPSC physician. Occasionally, FPSC physicians, particularly those with extra qualifications, can perform consultations. Nurse Practitioners can also complete consultation notes.
- Discharge Summary - A discharge summary is a clinical document that provides a clear, comprehensive overview of a patient's hospital stay along with the information required to support safe, continuous care after discharge. It signifies the end of a hospital or long-term care stay and typically includes the reason for admission, key diagnoses, significant events and interventions, treatments provided, the patient's condition at discharge, and instructions or plans for follow-up care. The discharge summary is usually completed by the most responsible provider (MRP) at the end of an inpatient stay, but since it can summarize medical events relating to multiple disciplines, it is often misleading to assign the discharge summary to a specific discipline. When a patient has been seen by multiple services during their hospitalization, the summary is generally written by the service responsible for the patient at the time of discharge with a nonspecified SMD. Other services typically use a Transfer note or Progress note to signify the end of their consultation or care period. If a person is admitted and discharged by the same service, then it is appropriate to add an SMD to the discharge note type. In rare cases, two discharge summaries may be produced when two services are closely involved in care at discharge, and each has community care instructions to convey — although in this situation, it is generally more appropriate for the non-MRP service to write a Plan of Care document instead.
- Referral Note - A referral note is a clinical document that provides a clear, comprehensive summary of a patient's condition and the specific clinical question prompting a request for specialist assessment. It typically includes the reason for referral, relevant medical history, current concerns or findings, prior investigations or treatments, and the referring provider's clinical impression and objectives for consultation. Completed by a primary care provider or other treating clinician when seeking additional expertise, the referral note initiates the consultation process and supports continuity of care by ensuring the consulting specialist receives the information needed for an informed assessment. The SMD assigned to the referral note is the SMD of the person receiving the referral.
| # |
Part Number |
Canadian English Part Display Name |
Canadian French Part Display Name |
| 1. |
LP173205-8 |
Admission |
Évaluation à l'admission |
| 2. |
LP173110-0 |
Consultation |
Consultation |
| 3. |
LP173221-5 |
Discharge Summary |
Résumé à la sortie |
| 4. |
LP173238-9 |
Referral |
Orientation |