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Electronic Forms and Signature Capture – patient intake forms, new patient forms, consent forms, health history forms, HIPAA portability forms, and other data-driven or signature captured forms are prevalent in today's healthcare organizations. Unfortunately, the majority of them are paper-based as of the time this article was written.
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 ...
SAMPLE history is a mnemonic acronym to remember key questions for a person's medical assessment. [1] The SAMPLE history is sometimes used in conjunction with vital ...
The Patient-Reported Outcomes Measurement Information System [1] (PROMIS) provides clinicians and researchers access to reliable, valid, and flexible measures of health status that assess physical, mental, and social well–being from the patient perspective. PROMIS measures are standardized, allowing for assessment of many 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 ...
The Clinical History of the [Spanish] National Health System (Historia Clínica Digital del Sistema Nacional de Salud, HCDSNS) is intended to guarantee citizens and health professionals access to whatever clinical information is relevant for medical care of a particular patient. This history should be available at all authorized locations, but ...
He entered the Spanish Mission-style facility, located 60 miles north of Los Angeles, under the wrenching spell of heroin withdrawal. In the room Peterson shared with 50 other patients, he was the only drug addict. Not once did a doctor treat him, a nurse attend to him or a psychiatrist hear his story.
It is the patient's progress since the last visit, and overall progress towards the patient's goal from the physician's perspective. In a pharmacist's SOAP note, the assessment will identify what the drug related/induced problem is likely to be and the reasoning/evidence behind it.