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Progress notes are written in a variety of formats and detail, depending on the clinical situation at hand and the information the clinician wishes to record. One example is the SOAP note , where the note is organized into S ubjective, O bjective, A ssessment, and P lan sections.
The system includes report forms for multiple informants – the Child Behavior Checklist (CBCL) is used for caregivers to fill out ratings of their child's behavior, the Youth Self Report Form (YSR) is used for children to rate their own behavior, and the Teacher Report Form (TRF) is used for teachers to rate their pupil's behavior. The ASEBA ...
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.
In an approach to psychotherapy called focused acceptance and commitment therapy (FACT) the four square tool is a tabular method similar in appearance to a decisional balance sheet. [34] The four square tool shows four sets of behaviors: positive behaviors (called "workable" behaviors) and negative behaviors (called "unworkable" behaviors) that ...
The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.
Free and open-source software portal; This is a category of articles relating to notetaking software which can be freely used, copied, studied, modified, and redistributed by everyone that obtains a copy: "free software" or "open-source software".
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