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  2. Progress note - Wikipedia

    en.wikipedia.org/wiki/Progress_note

    Progress Notes are the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. [1] Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review. Progress ...

  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. 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 ...

  5. Admission note - Wikipedia

    en.wikipedia.org/wiki/Admission_note

    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.

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  7. Beck Anxiety Inventory - Wikipedia

    en.wikipedia.org/wiki/Beck_Anxiety_Inventory

    Three samples of [1,086] psychiatric outpatients [456 men, mean age 36.35; and 630 women, mean age 35.69] [...] at the Center for Cognitive Therapy in Philadelphia, Pennsylvania, from [1980 to 1986.] The resulting Beck Anxiety Inventory (BAI) is a 21-item scale that showed high internal consistency (a = .92) and test-retest reliability over 1 ...

  8. Physical examination - Wikipedia

    en.wikipedia.org/wiki/Physical_examination

    The routine physical, also known as general medical examination, periodic health evaluation, annual physical, comprehensive medical exam, general health check, preventive health examination, medical check-up, or simply medical, is a physical examination performed on an asymptomatic patient for medical screening purposes.

  9. Individualized Education Program - Wikipedia

    en.wikipedia.org/wiki/Individualized_Education...

    A matrix is drafted containing the student's present level of performance, indicators about ways the student's disability influences participation and progress in the general curriculum, a statement of measurable goals that include benchmarks or short-term objectives, the specific educational services to be provided which include program ...

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