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SAMPLE history is a mnemonic acronym to remember key questions for a person's medical assessment. [1] The SAMPLE history is sometimes used in conjunction with vital signs and OPQRST.
A health risk assessment (also referred to as a health risk appraisal and health & well-being assessment) is a questionnaire about a person's medical history, demographic characteristics and lifestyle. It is one of the most widely used screening tools in the field of health promotion and is often the first step in multi-component health ...
A health assessment is a plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history. It is done to detect diseases early in people that ...
The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient 's chart, along with other common formats, such as the admission note. [1] [2] Documenting patient encounters in the medical record is an integral part of practice workflow ...
The Comprehensive Health Assessment Program is a clinically successful [1] system for providing comprehensive medical histories for patients with disabilities. The information is stored in one central location, completed by the patient with their carers and practitioners.
SF-36. The Short Form (36) Health Survey is a 36-item, patient-reported survey of patient health. The SF-36 is a measure of health status and an abbreviated variant of it, the SF-6D, is commonly used in health economics as a variable in the quality-adjusted life year calculation to determine the cost-effectiveness of a health treatment.
The nine-item Patient Health Questionnaire ( PHQ-9) is a depressive symptom scale and diagnostic tool introduced in 2001 to screen adult patients in primary care settings. The instrument assesses for the presence and severity of depressive symptoms and a possible depressive disorder. [1] [2] [3] The PHQ-9 is a component of the larger self-administered Patient Health Questionnaire (PHQ), but ...
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.
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