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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 assessment should not be used alone to diagnose a child with an anxiety disorder, however research suggest it is a reliable and useful tool when used along with clinical interviewing diagnose anxiety disorders. The SCARED's treatment sensitivity means that it is useful in both clinical and research settings to measure symptoms and presence ...
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 ...
This framework became widely used in both medical and mental health settings, offering a structured yet flexible approach to documentation that supported clinical reasoning and treatment planning. [65] [66] Progress notes also gained prominence in mental health, tracking clients’ clinical status and treatment progress across sessions.
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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.
According to Beck's publisher, 'When Beck began studying depression in the 1950s, the prevailing psychoanalytic theory attributed the syndrome to inverted hostility against the self.' [3] By contrast, the BDI was developed in a novel way for its time; by collating patients' verbatim descriptions of their symptoms and then using these to structure a scale which could reflect the intensity or ...
The mini–mental state examination (MMSE) or Folstein test is a 30-point questionnaire that is used extensively in clinical and research settings to measure cognitive impairment. [1] [2] It is commonly used in medicine and allied health to screen for dementia. It is also used to estimate the severity and progression of cognitive impairment and ...
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