opnameverslag

Opnameverslag is a Dutch term that translates to admission report or admission note in English. It is a medical document created by a healthcare professional when a patient is admitted to a hospital or other healthcare facility. The primary purpose of an opnameverslag is to provide a comprehensive summary of the patient's condition, medical history, and the reasons for admission.

This report typically includes details such as the patient's personal information, the date and time of admission, the admitting physician, and the primary complaint or reason for seeking medical care. It also contains a thorough account of the patient's medical history, including past illnesses, surgeries, allergies, and current medications. A physical examination performed upon admission is usually documented, along with any initial diagnostic tests ordered or performed.

The opnameverslag serves as a crucial communication tool among the healthcare team. It ensures that all medical personnel involved in the patient's care have access to consistent and accurate information, facilitating coordinated treatment and reducing the risk of medical errors. The information contained within the opnameverslag forms the foundation for the patient's ongoing medical record and treatment plan throughout their stay. It is a legal document and a vital part of patient documentation in Dutch healthcare.