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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 ...

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  4. 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.

  5. Chief complaint - Wikipedia

    en.wikipedia.org/wiki/Chief_complaint

    The chief complaint, formally known as CC in the medical field, or termed presenting complaint (PC) in Europe and Canada, forms the second step of medical history taking. It is sometimes also referred to as reason for encounter (RFE), presenting problem, problem on admission or reason for presenting.

  6. 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.

  7. Individualized Education Program - Wikipedia

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

    An eligible student is any child in the U.S. between the ages of 3–21 attending a public school and has been evaluated as having a need in the form of a specific learning disability, autism, emotional disturbance, other health impairments, intellectual disability, orthopedic impairment, multiple disabilities, hearing impairments, deafness ...

  8. 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 ...

  9. Direct support professional - Wikipedia

    en.wikipedia.org/wiki/Direct_support_professional

    DSPs work directly with individuals. This means they'll often spend extended hours in the home or care facilities of their clients, and help provide day-to-day care with activities such as showering, toileting, eating, traveling, scheduling appointments, handling finances, taking medications, and more.

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