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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 SUDS may be used as a benchmark for a professional or observer to evaluate the progress of treatment. In desensitization-based therapies, such as those listed below, the patients' regular self assessments enable them to guide the clinician repeatedly as part of the therapeutic dialog. [2] The SUD-level was developed by Joseph Wolpe in 1969. [3]
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.
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.
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Therapeutic assessment is a psychological assessment procedure which aims to help people gain insight and apply this new insight to problems in their life. [1] This paradigm is contrasted with the traditional, information-gathering model of psychological assessment, the main goal of which is to accurately diagnose, plan treatments, and evaluate treatment effectiveness.
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