1. What type of assessment is recommended for patients you're seeing for the first time?
Answer: A comprehensive assessment is recommended, which includes a comprehensive health history
and a complete physical examination.
2. What components are included in a comprehensive health history and physical examination?
Answer: A comprehensive health history includes all elements of the patient's health history, while a
complete physical examination includes all parts of the physical examination.
3. Where is subjective data typically recorded in the medical chart?
Answer: Subjective data is usually recorded in the history section of the medical chart, which includes
information provided by the patient.
4. Where is objective data typically recorded in the medical chart?
Answer: Objective data is usually recorded in the physical examination findings section of the medical
chart, which includes information obtained through physical examination.
5. What are the six components of a comprehensive health history?
Answer: The six components are:
- Chief complaint(s)
- History of present illness
- Past medical history
- Family history
- Social history
- Review of systems
, 6. What identifying data should be collected from patients?
Answer: The following identifying data should be collected:
- Age
- Gender
- Occupation
- Marital status
7. What is a patient's chief complaint?
Answer: A patient's chief complaint is the one or more symptoms that are causing them to seek care.
8. What information should be included in an adult patient's past medical history?
Answer: The past medical history should include information from four categories:
- Medical
- Surgical
- Ob/Gyn
- Psychiatric
9. What does a person's social history include?
Answer: A person's social history includes:
- Education level
- Family origin
- Current household
- Personal interests
- Lifestyle