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20 Cards in this Set
- Front
- Back
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Identifying data |
date, biographical data, source and reliability of history |
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chief complaint |
reason for seeking care (patient's own words), how do you elicit this information?, be sure to utilize appropriate attending behaviors and emphathy |
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History of present illness |
allows patient to describe problem in detail , assists with assessment of coping abilities, if client is healthy can ask how client views their health, |
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symptoms analysis |
O-onset (setting, course, duration) P-place/precipitating/palliative factors Q-quality/quantity R-radiation S-Setting/sequelae T-timing/treatment
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Past medical history |
general health hospitalizations childhood illnesses operations accidents of injuries obstetric/sexual history serious or chronic illnesses childhood immunizations |
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current history |
allergies immunizations/screening tests environmental hazards/ safety OTC drugs exercise, leisure, sleep patterns herbals nutrition tobacco, alcohol, drugs current medications
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family history |
information on health or illness of parents, grandparents, and siblings use of genogram helpful |
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psychosocial history |
home/daily life socioeconomic status cultural issues personality life altering experiences religion/spiritual beliefs |
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spiritual assessment |
FAITH Tool (Faith, Apply, Involved, Treatment, Help) FICA |
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review of systems |
past and present health state of each body system double check for any omission of significant date evaluate health promotion practices roughly a head-to-toe order does not include physical/objective data |
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Order of assessment for Integumentary System |
inspection, palpation, identify and describe lesions |
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HEENT order of assessment |
head-inspect/palpate eyes-inspect ears-inspect and palpate outer pinna and tragus nose-check patency, inspect, palpate and transilluminate sinuses mouth-inspect throat-inspect/palpate |
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breast/axilla order of assessment |
inspect palpate describe nodules |
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female reproductive order of assessment |
inspect palpate |
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respiratory order of assessment |
inspection palpation percussion auscultation |
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cardiovascular order of assessment |
inspection palpation ausculation inspection of extremities |
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abdomen order of assessment |
inspection auscultation percussion palpation |
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musculoskeletal order of assessment |
inspection palpation Don't forget ROM and special tests |
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neurological order of assessment |
inspection palpation of strength |
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Order of assessment for males |
inspection palpation |
