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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 ...

  3. 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 ...

  4. Psychiatric history - Wikipedia

    en.wikipedia.org/wiki/Psychiatric_history

    A psychiatric history is the result of a medical process where a clinician working in the field of mental health (usually a psychiatrist) systematically records the content of an interview with a patient. This is then combined with the mental status examination to produce a "psychiatric formulation" of the person being examined.

  5. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    The traditional medical record for inpatient care can include admission notes, on-service notes, progress notes , preoperative notes, operative notes, postoperative notes, procedure notes, delivery notes, postpartum notes, and discharge notes. Personal health records combine many of the above features with portability, thus allowing a patient ...

  6. Saint Louis University Mental Status Exam - Wikipedia

    en.wikipedia.org/wiki/Saint_Louis_University...

    The Saint Louis University Mental Status (SLUMS) Exam is a brief screening assessment used to detect cognitive impairment. [1] It was developed in 2006 at the Saint Louis University School of Medicine Division of Geriatric Medicine, in affiliation with a Veterans' Affairs medical center . [ 2 ]

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