Comprehensive Health Assessment
– Exam 1 Study Guide
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
– Exam 1 Study Guide
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
