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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 ...
Clinical formulation. A clinical formulation, also known as case formulation and problem formulation, is a theoretically-based explanation or conceptualisation of the information obtained from a clinical assessment. It offers a hypothesis about the cause and nature of the presenting problems and is considered an adjunct or alternative approach ...
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 ...
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 ...
A structured interview (also known as a standardized interview or a researcher-administered survey) is a quantitative research method commonly employed in survey research. The aim of this approach is to ensure that each interview is presented with exactly the same questions in the same order. This ensures that answers can be reliably aggregated ...
Clinical mental health counseling. Clinical mental health counseling is a healthcare profession addressing issues such as substance abuse, addiction, relational problems, stress management, as well as more serious conditions such as suicidal ideation and acute behavioral disorders.
Case management is the coordination of community-based services by a professional or team to provide quality mental health care customized accordingly to individual patients' setbacks or persistent challenges and aid them to their recovery. [ 1 ][ 2 ] Case management seeks to reduce hospitalizations and support individuals' recovery through an ...
Rehabilitation counseling is focused on helping people who have disabilities achieve their personal, career, and independent living goals through a counseling process. Rehabilitation Counselors can be found in private practice, in rehabilitation facilities, hospitals, universities, schools, government agencies, insurance companies and other ...