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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 ...
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.
As the field of psychotherapy grew, standardized note-taking practices emerged to promote consistency and improve the quality of patient care. One major advancement was the introduction of SOAP notes in the 1960s, developed by Dr. Lawrence Weed to structure clinical notes in four categories: Subjective, Objective, Assessment, and Plan. This ...
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 ...
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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.
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A clinical formulation, also known as case formulation and problem formulation, is a theoretically-based explanation or conceptualisation of the information obtained from a clinical assessment.
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