Questions Assessment Review, ADPIE Nursing Process,
Subjective & Objective Data Collection, Health History
Interviewing, Physical Examination Techniques, Complete
Health Database, Focused Problem-Centered Assessment,
Follow-Up Assessment, Emergency Assessment, Evidence-
Based Practice, Holistic Health Dimensions, Social
Determinants of Health (SDOH), Health Disparities &
Equity, Chief Complaint Analysis, History of Present Illness
(HPI), OLD CART Symptom Analysis, PQRSTU Assessment
Framework, Past Medical History, Medication & Allergy
Assessment, Family Health History, Review of Systems
(ROS), Clinical Reasoning Skills, Nursing Diagnosis
Preparation, Patient-Centered Care Planning, Health
Promotion Strategies, Risk Factor Identification |Latest
Updated 2026
Subjective data
information gathered from interview/history taking
-what the patient tells you or what the patient STATES
-you can't prove or observe the data
-EX. pain
objective data
information from your physical exam
,-what is OBSERVED by inspecting, percussing, palpating, auscultating
EX. BP, heart rate, vital signs
5 steps of nursing process (ADPIE)
-assessment
-diagnosis
-planning
-intervention
-evaluation
elements that are included in the assessment phase of the nursing process
-process used to evaluate the health status of a person
-systemic data collection that provides information to facilitate a plan to deliver the best care
purpose of the health assessment
-determine a patients health status
-determine patients risk factors
-determine the need for health education
-develop a nursing plan of care
complete health database
describes current and past health state and forms baseline to measure all future changes
,what is included in a complete health database
-a complete health history
-full physical examination
-yielding the first diagnosis
a comprehensive health assessment includes
-patients current health problems
-past history
-family history
-review of body systems
-health patterns
when to obtain a complete health history
-every person needs a complete health assessment
-ideally done on admission
-appropriate for new patients in all settings (nursing home, home health care, new patients to
a clinic)
3 types of databases
focused, follow-up, emergency
, focused (episodic/problem-centered) database
-used for limited or short term problem
-appropriate for established patients
-smaller in scope and more targeted that complete
EX. labor and delivery
follow-up database
-evaluates the status of any identified problem at regular intervals to follow-up on short-term
and chronic health problems
-evaluation of a previously identified problems
EX. patient had a hip replacement and came back to hospital 14 days later for check up
emergency database
-call for rapid collection of crucial data
-rapid assessment often occurs while performing lifesaving measures
-assessing physically and TREATING
sign
an objective, observable phenomenon that can be identified by another person
symptom