1
Identifying signs and symptoms (Noticing)
Data is normal, abnormal or has changed.
Subj Image
Obj
2
Gathering complet and accurate data (Noticing)
Data from all available sources.
Pt-interview and assessment Image
emr-health hx and dx
meds-MAR/TAR
spouse/cg-interview, when
labs, dx reports, etc
3
Assessing Systematically and Comprehensively (Noticing)
Systemic method or assessment
1. Head-to-toe Image
2. pain assessment
3. focused assessment
4. disease process
, 4
Predicting (and managing) potential complications (noticing)
When a situation has risks of complications
1. NPO-dehydrate Image
2. wound/incision-infection
3. immobility-DVT
5
Identifying Assumptions (Noticing)
Arriving at a conclusion without evidence.
1. non-compliance Image
2. dementia
6
Clustering related information (Interpreting)
Grouping together information with a common theme to determine issues, problems, or concerns.
1. Physical: LOC, CNS, GI, vision Image
2. Meds: treatment/adverse
3. Medical hx: current Dc
4. Physiological : Widow, work hx, support
5. Dx tests: MRI, CT, 12 lead EKG, etc
7
Identifying signs and symptoms (Noticing)
Data is normal, abnormal or has changed.
Subj Image
Obj
2
Gathering complet and accurate data (Noticing)
Data from all available sources.
Pt-interview and assessment Image
emr-health hx and dx
meds-MAR/TAR
spouse/cg-interview, when
labs, dx reports, etc
3
Assessing Systematically and Comprehensively (Noticing)
Systemic method or assessment
1. Head-to-toe Image
2. pain assessment
3. focused assessment
4. disease process
, 4
Predicting (and managing) potential complications (noticing)
When a situation has risks of complications
1. NPO-dehydrate Image
2. wound/incision-infection
3. immobility-DVT
5
Identifying Assumptions (Noticing)
Arriving at a conclusion without evidence.
1. non-compliance Image
2. dementia
6
Clustering related information (Interpreting)
Grouping together information with a common theme to determine issues, problems, or concerns.
1. Physical: LOC, CNS, GI, vision Image
2. Meds: treatment/adverse
3. Medical hx: current Dc
4. Physiological : Widow, work hx, support
5. Dx tests: MRI, CT, 12 lead EKG, etc
7
