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Clinical formulation. 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 ...
SOAP note. 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 ...
Definition. 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 ...
Radiation treatment planning. In radiotherapy, radiation treatment planning ( RTP) is the process in which a team consisting of radiation oncologists, radiation therapist, medical physicists and medical dosimetrists plan the appropriate external beam radiotherapy or internal brachytherapy treatment technique for a patient with cancer .
POLST ( Physician Orders for Life-Sustaining Treatment) is an approach to improving end-of-life care in the United States, encouraging providers to speak with the severely ill and create specific medical orders to be honored by health care workers during a medical crisis. [1] POLST began in Oregon in 1991 and currently exists in 46 states ...
People who are diagnosed with a mental health disorder and a simultaneous substance use disorder are known as having a dual diagnosis. For example, someone with bipolar disorder who also has an alcohol use disorder would have dual diagnosis. On such occasions, two treatment plans are needed with the mental health disorder requiring treatment first.
One example is the SOAP note, where the note is organized into Subjective, Objective, Assessment, and Plan sections. 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.
A nursing care plan promotes documentation and is used for reimbursement purposes such as Medicare and Medicaid. The therapeutic nursing plan is a tool and a legal document that contains priority problems or needs specific to the patient and the nursing directives linked to the problems. It shows the evolution of the clinical profile of a patient.