(LATEST UPDATE
Comprehensive Adult Assessment Sequence
*Chief Complaint
*Hx of present illness
*Past medical Hx
*Past surgical Hx
*Family Hx
*Social Hx
*Allergies
*Medications
*Review of Symptoms of System
*Physical Exam
*Assessment Steps
*Tx Plan
Objective Data
what the health professional observes by inspecting, palpating, percussing, and auscultating during
the physical examination
Subjective Data
what the person says about himself or herself during history taking
, Normal Findings
findings that are within range
Abnormal Findings
findings that are outside of normal limits
Validity
The ability of a test to measure what it is intended to measure
Sensitivity
indicates how likely it is to detect a condition when it is actually present in a patient. A test with low
can be thought of as being too cautious in finding a positive result, meaning it will
err on the side of failing to identify a disease in a sick person.
Specificity
the percentage of true negatives out of all subjects who do not have a disease or condition. In
other words, it is the ability of the test or instrument to obtain normal range or negative results
for a person who does not have a disease.
History Taking
A step within the patient assessment process that provides detail about the patient's chief
complaint and an account of the patient's signs and symptoms.
*Ask open-ended questions and listen carefully to the patient's story.
*Craft a thorough and systematic sequence to history taking and physical examination.