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  2. Psychiatric-mental health nurse practitioner - Wikipedia

    en.wikipedia.org/wiki/Psychiatric-mental_health...

    The first step to becoming a psychiatric-mental health nurse practitioner is becoming a registered nurse (RN). First, it is required to earn a Bachelor of Science in Nursing (BSN) from an accredited program (typically 4 years, or alternatively, an Associate Degree in Nursing (ADN) followed by a Bachelor of Science in Nursing Completion (BSN completion) program.

  3. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    [1] [2] Documenting patient encounters in the medical record is an integral part of practice workflow starting with appointment scheduling, patient check-in and exam, documentation of notes, check-out, rescheduling, and medical billing. [3] Additionally, it serves as a general cognitive framework for physicians to follow as they assess their ...

  4. List of medical abbreviations: P - Wikipedia

    en.wikipedia.org/wiki/List_of_medical...

    PT: prothrombin time physical therapy (physiotherapy) Pt. patient (from Latin patiens, meaning "one who endures" or "one who suffers") PTA: percutaneous transluminal angioplasty post-traumatic amnesia prior to admission Peritonsillar abscess PTB: pulmonary tuberculosis: PTC: percutaneous transhepatic cholangiography: PTCA: percutaneous ...

  5. Medical record - Wikipedia

    en.wikipedia.org/wiki/Medical_record

    It states, amongst other things, the statutory duty of medical personnel to document the treatment of the patient in either hard copy or within the electronic patient record (EPR). This documentation must happen in a timely manner and encompass each and every form of treatment the patient receives, as well as other necessary information, such ...

  6. Nursing documentation - Wikipedia

    en.wikipedia.org/wiki/Nursing_documentation

    Electronic nursing documentation is an electronic format of nursing documentation an increasingly used by nurses. Electronic nursing documentation systems have been implemented in health care organizations to bring in the benefits of increasing access to more complete, accurate and up-to-date data and reducing redundancy, improving ...

  7. 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.

  8. Patient Health Questionnaire - Wikipedia

    en.wikipedia.org/wiki/Patient_Health_Questionnaire

    The Patient Health Questionnaire 2 item (PHQ-2) is an ultra-brief screening instrument containing the first two questions from the PHQ-9. [ 8 ] : 3 Two screening questions to assess the presence of a depressed mood and a loss of interest or pleasure in routine activities , and a positive response to either question indicates further testing is ...

  9. Medical history - Wikipedia

    en.wikipedia.org/wiki/Medical_history

    In contrast, a psychiatric history is frequently lengthy and in depth, as many details about the patient's life are relevant to formulating a management plan for a psychiatric illness. The information obtained in this way, together with the physical examination, enables the physician and other health professionals to form a diagnosis and ...

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