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2. Progress note - Wikipedia

   en.wikipedia.org/wiki/Progress_note

   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.

3. SOAP note - Wikipedia

   en.wikipedia.org/wiki/SOAP_note

   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.

4. Outcome Questionnaire 45 - Wikipedia

   en.wikipedia.org/wiki/Outcome_Questionnaire_45

   The Outcome Questionnaire 45 (OQ-45), created by Gary M Burlingame and Michael J. Lambert at Brigham Young University, is a 45-item multiple-choice self-report inventory used to measure psychotherapy progress in adults patients.

5. 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.

6. Assessment and plan - Wikipedia

   en.wikipedia.org/wiki/Assessment_and_plan

   The assessment and plan (abbreviated A/P" [1] or A&P) is a component of an admission note. Assessment includes a discussion of the differential diagnosis and supporting history and exam findings. The plan is typically broken out by problem or system. Each problem should include: brief summary of the problem, perhaps including what has been done ...

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