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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.
Physicians are generally required to generate at least one progress note for each patient encounter. Physician documentation is then usually included in the patient's chart and used for medical, legal, and billing purposes. Nurses are required to generate progress notes on a more frequent basis, depending on the level of care and may be ...
The following diagnostic systems and rating scales are used in psychiatry and clinical psychology. This list is by no means exhaustive or complete. This list is by no means exhaustive or complete. For instance, in the category of depression, there are over two dozen depression rating scales that have been developed in the past eighty years.
This is a list of psychiatric medications used by psychiatrists and other physicians to treat mental illness or distress. The list is ordered alphabetically according to the condition or conditions, then by the generic name of each medication. The list is not exhaustive and not all drugs are used regularly in all countries.
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 ...
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.
This is a list of mnemonics used in medicine and medical science, categorized and alphabetized. A mnemonic is any technique that assists the human memory with information retention or retrieval by making abstract or impersonal information more accessible and meaningful, and therefore easier to remember; many of them are acronyms or initialisms which reduce a lengthy set of terms to a single ...
It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]
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