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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 Hamilton Rating Scale for Depression" (PDF). Archived from the original (PDF) on 2007-11-20 (49.0 KB) Clinically Useful Psychiatric Scales: HAM-D (Hamilton Depression Rating Scale). Accessed March 6, 2009. Hamilton Depression Rating Scale - Original scientific paper published in 1960 in Psychiatry out of Print website. Accessed June 27, 2008.
Consultation Note - The Consultation Note is generated by a request from a clinician for an opinion or advice from another clinician. [ 7 ] Continuity of Care Document - The Continuity of Care Document (CCD) represents a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare ...
An XML element in a CDA supports unstructured text, as well as links to composite documents encoded in pdf, docx, or rtf, as well as image formats like jpg and png. [ 3 ] It was developed using the HL7 Development Framework (HDF) and it is based on the HL7 Reference Information Model (RIM) and the HL7 Version 3 Data Types.
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.
Progress notes are written in a variety of formats and detail, depending on the clinical situation at hand and the information the clinician wishes to record. One example is the SOAP note , where the note is organized into S ubjective, O bjective, A ssessment, and P lan sections.
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The Profile of Mood States (POMS) is a psychological rating scale used to assess transient, distinct mood states. This scale was developed by McNair, Droppleman, and Lorr. [ 1 ] Advantages of using this assessment include the simplicity of administration and ease of participant understanding.