Practice questions for this set
Terms in this set (86)
What the person tells you
subjective data - History - Chief complaint through review of systems
-Reported by patient to you
What you detect form the examination
objective data -All physical examination findings
-What you See, Hear, Feel , Smell, and Touch
1/13
, 8/28/24, 4:44 AM
Identifying Data
Reliability
Chief Complaint (C/C)
History of present Illness (HPI)
Allergies and reactions
Medications
Components of the Adult Health History
Past Medical History
Family History
Social History
Review of Systems (ROS)
Health Maintenance/ Health Promotion
"Simple Concise Statements!"
health history and complete physical examination, usually conducted when a patient
Comprehensive Assessment
first enters a health care setting; provides a baseline for comparing later assessment
Problem or Focused
Episodic Assessment SOAP
Daily Progress Note
Patient Reports or Affirms a Finding
Pertinent Positives i.e. Weight loss x 3 weeks
Cough with mucus production
Patient denies a finding
Pertinent Negative i.e. No nausea or vomiting or constipation
Denies Fever
O - Onset (date)
L - Location (i.e. 1st finger)
D - Duration (how long or occurrences)
C - Character (describe)
"OLD CART" HPI
A - Aggravating/ Alleviating Factors
(what makes worse or helps)
R - Radiation (pain radiate anywhere)
T - Timing (starts/ how long)
Name, Dosage (milligrams and the number of tablets/capsules), frequency (daily, every
eight hours), route of delivery (orally, patch, eye drops, etc.), last dose
OTC
Herbals
Vitamins
Medications documentation should include Supplements
PRN or taken regularly
Reason for use of product or importance
DAW - (Dispense as written= Name brand only) vs.
generic
Medication Allergies
2/13
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller Denyss. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $7.99. You're not tied to anything after your purchase.