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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 ...
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 ...
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.
Mindfulness-based stress reduction is an eight-week program that helps train people to help with their stress, anxiety, depression, and pain. It was developed by Jon Kabat-Zinn in the 1970s. The program uses a combination of mindfulness meditation, body awareness, yoga, and exploration of patterns of behavior, thinking, feeling, and action. One ...
A number of researchers have explored HADS data to establish the cut-off points for caseness of anxiety or depression. Bjelland et al (2002) [3] through a literature review of a large number of studies identified a cut-off point of 8/21 for anxiety or depression. For anxiety (HADS-A) this gave a specificity of 0.78 and a sensitivity of 0.9.
Hamilton Rating Scale for Anxiety (HAM-A) Unlike most other psychological symptom scales listed in this section, clinicians use this scale to help evaluate the mental health of people, usually under treatment, who have been diagnosed with an anxiety disorder; it is not used with the general population samples. [58]
The patient may have more than one problem and these may be related, such as posttraumatic stress disorder and alcohol abuse or seemingly unrelated, such as panic disorder and premature ejaculation. The patient is unlikely to present a diagnosis and is more likely to describe the nature of their problems in common language.
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. [9]
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