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Bates- Advance Health Assessment Quiz 2 Flashcards _ 100- sure Answers.pdf
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8/28/24, 4:44 AMJeremiah
Bates' Advance Health Assessment Quiz 2
13 terms
me
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
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, 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
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