37 questions covering Modules 1 and 2
Week 1 Objectives:
1.To understand the components of a complete or focused assessment
Complete or comprehensive assessment:
Usually done with initial contact
Inquiring about your subjective components
Chief complaint- the reason the patient is seeking care in quotes “”
HPI- detailed description of the primary problem using symptom
analysis
Past medical history
Diagnoses with dates
Childhood and adult illness
Surgeries with dates
Immunizations
Pediatric, adolescent, and adult
Serious injury or trauma- h/x transfusions
Medications- Prescription and OTC
Allergies and response
Screening exams
Psychiatric or mental health issues
Family History- age and health for three generations
Coronary artery disease, cholesterol
Diabetes mellitus
Hypertension, stroke
Tuberculous
Asthma
Bleeding, anemia
Alcoholism
Weight, mental health
Social/Personal History
Ethanol/drug exposure
Tobacco (type, PPD, pack year (#ppd x # years))
Ask, advise, assess, assist, arrange
Occupation
Nutrition
Exercise
Home life, support system, housing, safety, SES
Exposures, travel
Stress management
Sleep patterns