NP Steps to Assessing a Patient (4) correct answers History
Physical
Impression
Plan
History correct answers The subjective information
Patient's report or "story", guided by your questions
May also include hospital/outpatient records
Physical correct answers Examination, labs, diagnostics, etc.
Nothing that you can't see, feel, hear, or touch belongs here
NO DIAGNOSIS
A physical exam of every body system covered in the other 3 categories
Impression correct answers What do you think of the patient- what's going on?
Can be a simple status of a known problem or extensive thought about differential diagnoses
, Ex. The patient's chest pain is most consistent with GERD, with differential diagnoses including
XYZ
Plan correct answers Includes both what you did today and/or what you will do
For each and every problem
4 Components of the Plan correct answers Diagnostics
Therapeutics
Education
Follow-Up
Health History correct answers The patient's story of past and present events which affect or may
affect his/her present or future health status
Purposes of the Health History (2) correct answers Data acquisition
To establish a working relationship between the patient and the healthcare provider
Ways to provide a comfortable environment for patients correct answers Patient is ideally
dressed, not in gown
Note body language