Nurs 3309 - Exam 1 Questions and Answers 100%
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Terms in this set (237)
things a person tells you about that you cannot
subjective data
observe through your senses; symptoms
what the health professional observes by inspecting,
objective data palpating, percussing, and auscultating during the
physical examination
1. Biographic data
2. Reason for seeking care
3. Present health or history of present illness
4. Past history
Health History Sequence 5. Medication reconciliation
6. Family history
7. Review of systems
8. Functional assessment or activities of daily living
(ADLs)
name, address, phone number, age, birthdate, gender,
biographic data marital status, race, ethic origin, occupation, primary
language
Record who furnishes the information, judge how
Source of History reliable the informant seems and how willing, note
any special circumstances
Brief spontaneous statement in person's own words
Reason for seeking care
describing reason for visit
, subjective evidence person feels of a disease, such as
symptom
pain or a headache
objective evidence of disease such as a fever, lab
sign
reports, physical findings
OLDCARTS
-onset
-location
-duration
History of Present Illness
-character
(HPI)
-allieving/aggravating
-radiating
-time
-severity
-Provocative or palliative
-Quality or quantity
-Region or radiation
PQRSTU -Severity scale: 1-10
-Timing
-Understanding the patient's perception of the
problem.
-Childhood illnesses
-Accidents or injuries
-Serious or chronic illnesses
-Hospitalizations
Past Medical History -Operations
(PMH) -Obstetric history
-Immunizations
-Last examination date
-Allergies
-Current medications
A review of medical events in the patient's family
Family History (FH) including diseases that may be hereditary or place the
patient at risk
Correct
Save
Terms in this set (237)
things a person tells you about that you cannot
subjective data
observe through your senses; symptoms
what the health professional observes by inspecting,
objective data palpating, percussing, and auscultating during the
physical examination
1. Biographic data
2. Reason for seeking care
3. Present health or history of present illness
4. Past history
Health History Sequence 5. Medication reconciliation
6. Family history
7. Review of systems
8. Functional assessment or activities of daily living
(ADLs)
name, address, phone number, age, birthdate, gender,
biographic data marital status, race, ethic origin, occupation, primary
language
Record who furnishes the information, judge how
Source of History reliable the informant seems and how willing, note
any special circumstances
Brief spontaneous statement in person's own words
Reason for seeking care
describing reason for visit
, subjective evidence person feels of a disease, such as
symptom
pain or a headache
objective evidence of disease such as a fever, lab
sign
reports, physical findings
OLDCARTS
-onset
-location
-duration
History of Present Illness
-character
(HPI)
-allieving/aggravating
-radiating
-time
-severity
-Provocative or palliative
-Quality or quantity
-Region or radiation
PQRSTU -Severity scale: 1-10
-Timing
-Understanding the patient's perception of the
problem.
-Childhood illnesses
-Accidents or injuries
-Serious or chronic illnesses
-Hospitalizations
Past Medical History -Operations
(PMH) -Obstetric history
-Immunizations
-Last examination date
-Allergies
-Current medications
A review of medical events in the patient's family
Family History (FH) including diseases that may be hereditary or place the
patient at risk
