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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 is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process .
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.
Psychiatric nursing or mental health nursing is the appointed position of a nurse that specialises in mental health, and cares for people of all ages experiencing mental illnesses or distress. These include: neurodevelopmental disorders , schizophrenia , schizoaffective disorder , mood disorders , addiction , anxiety disorders , personality ...
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.
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Different psychological schools or models utilize clinical formulations, including cognitive behavioral therapy (CBT) and related therapies: systemic therapy, [5] psychodynamic therapy, [6] and applied behavior analysis. [7] The structure and content of a clinical formulation is determined by the psychological model.
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