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  2. Progress note - Wikipedia

    en.wikipedia.org/wiki/Progress_note

    Progress notes serve as a record of events during a patient's care, allow clinicians to compare past status to current status, serve to communicate findings, opinions and plans between physicians and other members of the medical care team, and allow retrospective review of case details for a variety of interested parties.

  3. Medical diagnosis - Wikipedia

    en.wikipedia.org/wiki/Medical_diagnosis

    A treatment plan is proposed which may include therapy and follow-up consultations and tests to monitor the condition and the progress of the treatment, if needed, usually according to the medical guidelines provided by the medical field on the treatment of the particular illness. [citation needed]

  4. Clinical pathway - Wikipedia

    en.wikipedia.org/wiki/Clinical_pathway

    A clinical pathway is a multidisciplinary management tool based on evidence-based practice for a specific group of patients with a predictable clinical course, in which the different tasks (interventions) by the professionals involved in the patient care are defined, optimized and sequenced either by hour (ED), day (acute care) or visit (homecare).

  5. Clinical formulation - Wikipedia

    en.wikipedia.org/wiki/Clinical_formulation

    Formulations can vary in temporal scope from case-based to episode-based or moment-based, and formulations may evolve during the course of treatment. [20] Therefore, ongoing monitoring, testing, and assessment during treatment are necessary: monitoring can take the form of session-by-session progress reviews using quantitative measures, and ...

  6. Nursing care plan - Wikipedia

    en.wikipedia.org/wiki/Nursing_care_plan

    A computerised nursing care plan is a digital way of writing the care plan, compared to handwritten. Computerised nursing care plans are an essential element of the nursing process. [8] Computerised nursing care plans have increased documentation of signs and symptoms, associated factors and nursing interventions. [8]

  7. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    The plan will also include goals of therapy and patient-specific drug and disease-state monitoring parameters. This should address each item of the differential diagnosis. 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 ...