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For patients who have multiple health problems that are addressed in the SOAP note, a plan is developed for each problem and is numbered accordingly based on severity and urgency for therapy. A note of what was discussed or advised with the patient as well as timings for further review or follow-up are generally included.
An intensive outpatient program (IOP), also known as an intensive outpatient treatment (IOT) program, is a structured non-residential psychological treatment program which addresses mental health disorders and substance use disorders (SUDs) that do not require detoxification through a combination of group-based psychotherapy, individual psychotherapy, family counseling, educational groups, and ...
A clinical formulation, also known as case formulation and problem formulation, is a theoretically-based explanation or conceptualisation of the information obtained from a clinical assessment. It offers a hypothesis about the cause and nature of the presenting problems and is considered an adjunct or alternative approach to the more ...
Whether any movement, pressure (such as palpation) or other external factor makes the problem better or worse. This can also include whether the symptoms relieve with rest. Quality of the pain This is the patient's description of the pain.
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.
Mental health encompasses emotional, psychological, and social well-being, influencing cognition, perception, and behavior.According to the World Health Organization (WHO), it is a "state of well-being in which the individual realizes his or her abilities, can cope with the normal stresses of life, can work productively and fruitfully, and can contribute to his or her community". [1]
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