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1. subjective data things a person tells you about that you cannot observe through your
senses; symptoms ; "I have a headache"
2. objective data information that is seen, heard, felt, or smelled by an observer; signs as
in vital signs or lab values or observations
3. comprehensive assess- health history and complete physical examination, usually conducted
ment when a patient first enters a health care setting; provides a baseline for
comparing later assessment
4. Problem-based/fo- involves a history and examination that are limited to a specific problem
cused assessment. or complaint ; for example coming in for a sore throat
5. episodic/follow-up as- usually done when a patient is following up with a health care provider
sessment for a previously identified problem ; blood pressure and added medica-
tion
6. Screening Assessment Short exam focused on disease detection. (Ex. BP screening, glucose
screening, colesterol screening, colorectal screening).
7. Context of care ; two the circumstances or situations related to the health care delivery ; a
reasons we seek care problem or preventing a problem
8. components of health Health History, Physical Exam , Documentation of Data/clinical manifes-
assessment tations
9. SOAP subjective, objective, assessment, plan
10. primary prevention Efforts to prevent an injury or illness from ever occurring - vaccine, check
ups, sports physicals
11. secondary prevention limit the effects of an injury or illness that you cannot completely prevent
- early detection - breast exam -mammograms - BP screening
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