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Another example is the DART system, organized into Description, Assessment, Response, and Treatment. [2] Documentation of care and treatment is an extremely important part of the treatment process. Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization.
The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.
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.
The situation, task, action, result (STAR) format is a technique [1] used by interviewers to gather all the relevant information about a specific capability that the job requires.
A distinguishing facet of occupational therapy is that therapists often espouse the use theoretical frameworks to frame their practice. Many have argued that the use of theory complicates everyday clinical care and is not necessary to provide patient-driven care. [citation needed] Note that terminology differs between scholars.
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