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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 ...
Prognosis (Greek: πρόγνωσις "fore-knowing, foreseeing"; pl.: prognoses) is a medical term for predicting the likelihood or expected development of a disease, including whether the signs and symptoms will improve or worsen (and how quickly) or remain stable over time; expectations of quality of life, such as the ability to carry out daily activities; the potential for complications and ...
The plan will also include goals of therapy and patient-specific drug and disease-state monitoring parameters. This should address each item of the differential diagnosis. For patients who have multiple health problems that are addressed in the SOAP note, a plan is developed for each problem and is numbered accordingly based on severity and ...
Two aspects of the patient's state may be reported. The first aspect is the patient's current state, which may be reported as "good" or "serious," for instance. Second, the patient's short-term prognosis may be reported. Examples include that the patient is improving or getting worse.
A psychiatric assessment is most commonly carried out for clinical and therapeutic purposes, to establish a diagnosis and formulation of the individual's problems, and to plan their care and treatment. This may be done in a hospital, in an out-patient setting, or as a home-based assessment.
The investigators then obtain a standard set of clinical observations on each patient and a test or clinical follow-up to define the true state of the patient. They then use statistical methods to identify the best clinical predictors of the patient's true state. The probability of disease will depend on the patient's key clinical predictors.
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It offers a hypothesis about the cause and nature of the presenting problems and is considered an adjunct or alternative approach to the more categorical approach of psychiatric diagnosis. [1] In clinical practice, formulations are used to communicate a hypothesis and provide framework for developing the most suitable treatment approach.