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Summary Bates' Advance Health Assessment Quiz 2 rated A
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Bates' Advance Health Assessment Quiz 2 rated A
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Bates' Advance Health Assessment Quiz 2rated A
subjective data - What the person tells you
- History - Chief complaint through review of systems
-Reported by patient to you
objective data - What you detect form the examination
-All physical examination findings
-What you See, Hear, Feel , Smell, and Touch
Components of the Adult Health History - Identifying Data
Reliability
Chief Complaint (C/C)
History of present Illness (HPI)
Allergies and reactions
Medications
Past Medical History
Family History
Social History
Review of Systems (ROS)
,Bates' Advance Health Assessment Quiz 2
rated A
Health Maintenance/ Health Promotion
"Simple Concise Statements!"
Comprehensive Assessment - health history and complete physical examination,
usually conducted when a patient first enters a health care setting; provides a
baseline for comparing later assessment
Episodic Assessment - Problem or Focused
SOAP
Daily Progress Note
Pertinent Positives - Patient Reports or Affirms a Finding
i.e. Weight loss x 3 weeks
Cough with mucus production
Pertinent Negative - Patient denies a finding
i.e. No nausea or vomiting or constipation
Denies Fever
,Bates' Advance Health Assessment Quiz 2
rated A
"OLD CART" HPI - O - Onset (date)
L - Location (i.e. 1st finger)
D - Duration (how long or occurrences)
C - Character (describe)
A - Aggravating/ Alleviating Factors
(what makes worse or helps)
R - Radiation (pain radiate anywhere)
T - Timing (starts/ how long)
Medications documentation should include - 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
Supplements
PRN or taken regularly
Reason for use of product or importance
DAW - (Dispense as written= Name brand only) vs.
, Bates' Advance Health Assessment Quiz 2
rated A
generic
Medication Allergies
Past Medical History (PMH) - A listing of any illnesses the patient may have had in
the past; includes treatments and procedures performed.
- Significant past medical history
-Date of onset
- current state of condition
-recent exacerbations
- Surgical procedures
• When & why
- Serious injuries or trauma
- Hospitalizations
- Childhood illnesses
- Obstetric & Gynecological History:
- 1st Day LMP & Last P & P (result?)
- Contraception
- Immunization status
- Transfusions
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