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2. Progress note - Wikipedia

   en.wikipedia.org/wiki/Progress_note

   Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization. Progress notes serve as a record of events during a patient's care, allow clinicians to compare past status to current status, serve to communicate findings, opinions and plans between physicians and other ...

3. SOAP note - Wikipedia

   en.wikipedia.org/wiki/SOAP_note

   The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient 's chart, along with other common formats, such as the admission note. [1][2] Documenting patient encounters in the medical record is an integral part of practice workflow ...

4. Psychotherapy - Wikipedia

   en.wikipedia.org/wiki/Psychotherapy

   This framework became widely used in both medical and mental health settings, offering a structured yet flexible approach to documentation that supported clinical reasoning and treatment planning. [64] [65] Progress notes also gained prominence in mental health, tracking clients’ clinical status and treatment progress across sessions.

5. Mental status examination - Wikipedia

   en.wikipedia.org/wiki/Mental_status_examination

   The mental status examination (MSE) is an important part of the clinical assessment process in neurological and psychiatric practice. It is a structured way of observing and describing a patient's psychological functioning at a given point in time, under the domains of appearance, attitude, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight, and ...

6. Nursing documentation - Wikipedia

   en.wikipedia.org/wiki/Nursing_documentation

   A progress note is the record of nursing actions and observations in the nursing care process. [13] It helps nurses to monitor and control the course of nursing care. Generally, nurses record information with a common format. Nurses are likely to record details about a client's clinical status or achievements during the course of the nursing care.

7. Medical record - Wikipedia

   en.wikipedia.org/wiki/Medical_record

   A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, X-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health ...