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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.
Goal attainment scaling (GAS) is a therapeutic method that refers to the development of a written follow-up guide between the client and the counselor used for monitoring client progress. [1] GAS was first developed by Thomas Kiresuk and Robert Sherman in response to the wide variety of evaluation models regarding mental illness and treatment ...
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 ...
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.
In the field of medicine a patient history is an account of the significant events in the patient's life that have a relevance to the issue being addressed. The clinician taking the history guides the process in an attempt to achieve a succinct summary of these relevant details.
This is an alphabetical list of psychotherapies.. This list contains some approaches that may not call themselves a psychotherapy but have a similar aim of improving mental health and well-being through talk and other means of communication.
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