Comprehensive Patient Assessment - ANSWER -Is appropriate for new patients in
the office or hospital
-Provides fundamental and personalized knowledge about the patient
-Strengthens the clinician-patient relationship
-Helps identify or rule out physical causes related to patient concerns
-Provides a baseline for future assessments
-Creates a platform for health promotion through education and counseling
-Develops proficiency in the essential skills of physical examination
Focused Patient Assessment - ANSWER -Is appropriate for established patients,
especially during routine or urgent care visits
-Addresses focused concerns or symptoms
-Assesses symptoms restricted to a specific body system
-Applies examination methods relevant to assessing the concern or problem as
thoroughly and carefully as possible
Reliability - ANSWER varies according to the patient's memory, trust, and mood
Chief Complaint(s) - ANSWER The primary symptom or concern causing the
patient to seek care. It may be one or two concerns and rarely more than that
History of Present Illness - ANSWER -Amplifies the Chief Complaint; describes the
chronology of events as to how each symptom developed
-Includes patient's thoughts and feelings about the illness
-Pulls in relevant portions of the Review of Systems, called "pertinent positives and
negatives"
Past Medical History - ANSWER -Lists adult illnesses with dates for events in at
least four categories: medical, surgical, obstetric/gynecologic, and psychiatric
-May list childhood illnesses
-Includes health maintenance practices such as immunizations, screening tests,
lifestyle issues, and home safety
May include medications and allergies
Family History - ANSWER -Outlines or diagrams age and health, or age and cause
of death, of siblings, parents, and grandparents
-Documents presence or absence of specific illnesses in family, such as
hypertension, diabetes, or type of cancer
Personal and Social History - ANSWER -Includes any history of tobacco, alcohol,
or recreational drug use
-Describes sexual history
, -Describes educational level, family of origin, current household, personal interests,
and lifestyle
Review of Systems - ANSWER Documents presence or absence of common
symptoms related to each of the major body systems
OLDCART - ANSWER Onset
Location
Duration
Character
Aggravating or Alleviating factors
Radiation
Timing
Setting
CAGE - ANSWER -Have you ever felt the need to cut down on your drinking?
-Have people annoyed you by criticizing your drinking?
-Have you ever felt bad or guilty about your drinking?
-Have you ever had a drink first thing in the morning to steady your nerves or to get
rid of a hangover (eye-opener)?
The Five Ps+ - ANSWER -Partners
-Practices
-Protection from STIs
-Past History of STIs
-Pregnancy plans
-Plus (assessment of trauma, violence, sexual satisfaction, sexual health
concerns/problems, and support for sexual orientation and gender identity (SOGI)
FICA Spiritual Tool - ANSWER -Faith
-Importance/Influence
-Community
-Address
Social History should include: - ANSWER -Sexual orientation/gender identity
-Personal geographic map
-Significant relationships
-Local support systems
-Work history/occupation
-Education
-Lifestyle
-ADLs
-Nutrition
-Exercise
-Alcohol/Tobacco/Illicit drug use
-Safety measures
-Spirituality
-Sexual history
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