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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 ...
Nursing documentation mainly consists of a client's background information or nursing history referred as admission form, numerous assessment forms, nursing care plan and progress notes. These documents record the client's data captured at the relevant stages of the nursing process . [ 2 ]
The following diagnostic systems and rating scales are used in psychiatry and clinical psychology. This list is by no means exhaustive or complete. This list is by no means exhaustive or complete. For instance, in the category of depression, there are over two dozen depression rating scales that have been developed in the past eighty years.
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 ...
One school of psychotherapy which relies heavily on the formulation is cognitive analytic therapy (CAT). [14] CAT is a fixed-term therapy, typically of around 16 sessions. At around session four, a formal written reformulation letter is offered to the patient which forms the basis for the rest of the treatment.
In the next session, the same therapist sits with the patient as they watch the recording together. The therapist hits “pause” whenever there is an opportunity to dig deeper, searching for breakthroughs. In the third session, they outline potential triggers and vulnerabilities that could lead the patient back into a suicidal mode.
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