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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 Saint Louis University Mental Status (SLUMS) Exam is a brief screening assessment used to detect cognitive impairment. [1] It was developed in 2006 at the Saint Louis University School of Medicine Division of Geriatric Medicine , in affiliation with a Veterans' Affairs medical center . [ 2 ]
A psychiatric history is the result of a medical process where a clinician working in the field of mental health (usually a psychiatrist) systematically records the content of an interview with a patient. This is then combined with the mental status examination to produce a "psychiatric formulation" of the person being examined.
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.
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 information needs to be interpreted in the context of the physical examination elsewhere (e.g. chest, abdomen, neurological examinations in the case of the limping child or in the presence of any “red flags” in the unwell child. • Documentation of findings in the case notes is simple using a grid (see free resources)
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