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  2. Intake interview - Wikipedia

    en.wikipedia.org/wiki/Intake_interview

    The purpose of the intake interview often includes establishing and diagnosing any problems the client may have. [1] Usually, the clinician diagnoses the patient using criteria from the first two DSM axes. Some intake interviews include a mental status examination [2] During the intake interview, the clinician may determine a treatment plan. In ...

  3. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    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.

  4. Admission note - Wikipedia

    en.wikipedia.org/wiki/Admission_note

    Admission notes document the reasons why a patient is being admitted for inpatient care to a hospital or other facility, the patient's baseline status, and the initial instructions for that patient's care.

  5. SAMPLE history - Wikipedia

    en.wikipedia.org/wiki/SAMPLE_History

    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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  7. List of patient-reported quality of life surveys - Wikipedia

    en.wikipedia.org/wiki/List_of_patient-reported...

    It has been used to assess the effect of nadolol and topiramate, [113] regular water intake [114] and using migraine patients as trainers in preventive attack management. [115] Multiple sclerosis. The Patient Reported Outcome Indices for Multiple Sclerosis (PRIMUS) was developed in 2009 by Galen Research and funded by Novartis Pharmaceuticals ...

  8. Nursing assessment - Wikipedia

    en.wikipedia.org/wiki/Nursing_assessment

    Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse.Nursing assessment is the first step in the nursing process.

  9. Unlicensed assistive personnel - Wikipedia

    en.wikipedia.org/wiki/Unlicensed_assistive_personnel

    Measuring and recording intake and output (amount of food and drink consumed; amount of urine, stool, and vomit excreted) Emptying and recording the volume of surgical drains, such as Jackson-Pratt drains; Providing emotional and support services to patients, their families and other caregivers

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