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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 ...
The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient's chart, along with other common formats, such as the admission note. [1] [2] Documenting patient encounters in the medical record is an integral part of practice workflow ...
As the field of psychotherapy grew, standardized note-taking practices emerged to promote consistency and improve the quality of patient care. One major advancement was the introduction of SOAP notes in the 1960s, developed by Dr. Lawrence Weed to structure clinical notes in four categories: Subjective, Objective, Assessment, and Plan. This ...
Solution-focused (brief) therapy (SFBT) [1] [2] is a goal-directed collaborative approach to psychotherapeutic change that is conducted through direct observation of clients' responses to a series of precisely constructed questions. [3]
This construct refers to the temporal dimension of behavioural change. In the transtheoretical model, change is a "process involving progress through a series of stages": [11] Precontemplation ("not ready") – "People are not intending to take action in the foreseeable future, and can be unaware that their behaviour is problematic"
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