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Comprehensive Health Assessment Exam 100% correct
Components of a health assessment Healthy history
Physical examination
Reviewing data from the health record
Document the findings
Comprehensive health history Biographic data
Reason for seeking health care
History of present illness
Present health status
Past health history
Family history
Personal and psychosocial history
Review of systems
Subjective data Symptoms, perceived by the patient, reported by the patient
Objective data signs, observed, felt, heard, measured
Comprehensive Assessment detailed history at onset of care in primary care setting
Problem-based/focused assessment history and exam are limited to specific problem
episodic/follow-up assessment follow up for previously identified problem
Shift assessment assessment completed at each shift change
Screening assessment short exam focused on disease detection
Reason for seeking health care Also called "chief complaint" or "presenting problem",
recorded in quotes
O in OLDCARTS Onset - when did the symptoms begin
L in OLDCARTS Location - where are the symptoms
D in OLDCARTS Duration - how long do the symptoms last
C in OLDCARTS Characteristics - Describe the symptoms
A in OLDCARTS Aggravating factors - what makes the symptoms worse
R in OLDCARTS Related Symptoms - symptoms that may be related
T in OLDCARTS Treatments - Describe self treatment before seeking care
S in OLDCARTS Severity - describe severity of symptoms
, Present health status Health conditions, medications, allergies
Past health history Childhood illness, surgeries, hospitalizations,
accidents/injuries, immunizations, last examinations, obstetric
history
Family history Patients blood relative (parents, siblings, aunts, uncles,
grandparents), spouse, family history of conditions
Phases of interview Introduction, discussion, summary
Active listening listening with a purpose, focus on patient's response
Facilitation Use phrases to encourage patient to continue, "Go on",
"Uh-huh"
Clarification used to obtain more information about conflicting, vague
statements
Restatement Repeat patient to confirm interpretation
Reflection Ask patient questions to clarify phrase or
sentence, encourages elaboration
Confrontation Used when inconsistencies are noted between reports and
observations
Interpretation Opportunity to share conclusions drawn from data patient has
given, allows patient to confirm, deny or revise information
Summary Condenses data from interview to help clarify a sequence of
events
Communication skills that can diminish data Using medical
collection terminology Expressing
value judgements
Interrupting the patient
Being authoritarian or
paternalistic Using "why"
question
Standard precautions Measures to reduce the risk of transmitting infection from
bodily fluids and non-intact skin. These measures are used on
all clients - the potential for infection transmission always
exists
Comprehensive Health Assessment Exam 100% correct
Components of a health assessment Healthy history
Physical examination
Reviewing data from the health record
Document the findings
Comprehensive health history Biographic data
Reason for seeking health care
History of present illness
Present health status
Past health history
Family history
Personal and psychosocial history
Review of systems
Subjective data Symptoms, perceived by the patient, reported by the patient
Objective data signs, observed, felt, heard, measured
Comprehensive Assessment detailed history at onset of care in primary care setting
Problem-based/focused assessment history and exam are limited to specific problem
episodic/follow-up assessment follow up for previously identified problem
Shift assessment assessment completed at each shift change
Screening assessment short exam focused on disease detection
Reason for seeking health care Also called "chief complaint" or "presenting problem",
recorded in quotes
O in OLDCARTS Onset - when did the symptoms begin
L in OLDCARTS Location - where are the symptoms
D in OLDCARTS Duration - how long do the symptoms last
C in OLDCARTS Characteristics - Describe the symptoms
A in OLDCARTS Aggravating factors - what makes the symptoms worse
R in OLDCARTS Related Symptoms - symptoms that may be related
T in OLDCARTS Treatments - Describe self treatment before seeking care
S in OLDCARTS Severity - describe severity of symptoms
, Present health status Health conditions, medications, allergies
Past health history Childhood illness, surgeries, hospitalizations,
accidents/injuries, immunizations, last examinations, obstetric
history
Family history Patients blood relative (parents, siblings, aunts, uncles,
grandparents), spouse, family history of conditions
Phases of interview Introduction, discussion, summary
Active listening listening with a purpose, focus on patient's response
Facilitation Use phrases to encourage patient to continue, "Go on",
"Uh-huh"
Clarification used to obtain more information about conflicting, vague
statements
Restatement Repeat patient to confirm interpretation
Reflection Ask patient questions to clarify phrase or
sentence, encourages elaboration
Confrontation Used when inconsistencies are noted between reports and
observations
Interpretation Opportunity to share conclusions drawn from data patient has
given, allows patient to confirm, deny or revise information
Summary Condenses data from interview to help clarify a sequence of
events
Communication skills that can diminish data Using medical
collection terminology Expressing
value judgements
Interrupting the patient
Being authoritarian or
paternalistic Using "why"
question
Standard precautions Measures to reduce the risk of transmitting infection from
bodily fluids and non-intact skin. These measures are used on
all clients - the potential for infection transmission always
exists
