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9 Cards in this Set
- Front
- Back
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Objective data |
perceptible to the senses, such as signs that can be seen, heard, or felt and such things as laboratory reports |
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Subjective data |
pertains to or are are perceived by the affected individual only; emotions and experiences, such as pain and its severity |
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clinical history |
information available regarding a patient's condition; traditionally comprises data on localization, quality, chronology, setting, aggravating or alleviating factors, and associated manifestations |
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chronology |
time element of the history, usually including the onset, duration, frequency, and course of the symptoms |
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chief complaint |
primary medical problem as defined by the patient; important because it focuses the clinical history toward the single most important issue |
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leading questions |
undesirable method of questioning that provides information that may direct answers toward a suggested symptom or complaint |
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Localization |
determination of a precise area, usually through gentle palpation or careful wording of questions |
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quality |
description of the character of the symptoms, for example, the color, quantity, and consistency of blood or other body substances; size or number of lumps or lesions; frequency of urination or coughing; or character of pain |
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Sacred Seven |
-localization -chronology -quality -severity -onset -aggravating or alleviating factors -associated manifestations |
