Comprehensive Patient Assessment - ANSWER - Appropriate for new patients in the
office or hospital.
- Provides fundamental and personalized knowledge about patient.
- Strengthens the clinician-patient relationship.
- Helps identify or rule out physical causes related to patient concerns.
- Provides a baseline for future assessments.
- Creates a platform for health promotion through education and counseling.
- Develops proficiency in the skills of physical assessment.
Focused Patient Assessment - ANSWER - Appropriate for established patients, espe-
cially during routine or urgent care visits.
- Addresses focused concerns or symptoms.
- Assesses symptoms restricted to a specific body system.
- Applies examination methods relevant to assessing the concern or problem as thoroughly
and carefully as possible.
Subjective Information - ANSWER - The clinical record from the Chief Complaint (CC)
through the Review of Systems (ROS) is considered SUBJECTIVE information.
- Includes symptoms which are health concerns the patient tells the provider.
- Includes feelings, perceptions, and concerns obtained from the clinical interview.
- Examples: complaints of sore throat, headache, or pain.
Objective Information - ANSWER - All physical examination, laboratory information
and test data are objective data.
1
,Components of Comprehensive Adult Health History - ANSWER - Initial information
(Identifying patient information/source/reliability)
- Chief Complaint(s)
- History of Present Illness
- Past Medical History
- Family History
- Personal/Social History
- Review of Systems (ROS)
SNAPPS method - ANSWER - Summarize the history and findings.
- Narrow the differential diagnosis to two to three possibilities.
- Analyze the differential by comparing and contrasting the possibilities.
- Probe the preceptor by asking questions about alternative approaches or uncertainties.
- Plan the management of the patient's health issues.
- Select an issue from the case for self-directed learning.
Creating a Differential Diagnosis
*Hoofbeats = Horses NOT Zebras* - ANSWER - The differential diagnosis process in-
volves using clinical reasoning to distinguish between two or more conditions that share sim-
ilar signs and symptoms. Based on the CC the NP gathers information through PMH (subjec-
tive data) and physical examination (objective data) to establish a broad list of common &
uncommon diagnosis. As the provider collects more data, competing hypotheses are either
confirmed, disproved, or their priority changes.
Steps for Creating a Differential Diagnosis - ANSWER 1. Initially start with a broad list
of diagnoses until further information or data is obtained.
2. List your top diagnosis FIRST followed by other potential diagnoses for a specific problem
*but keep it problem oriented until you have an actual diagnosis.*
2
, 3. Aggressively prioritize work up of the most likely and most harmful (ie, life threatening)
diagnoses under consideration.
4. Prioritize the work up of ACUTE and REVERSIBLE diseases followed by CHRONIC and IRRE-
VERSIBLE (eg, delirium r/t a medical cause vs. chronic, progressive dementia).
5. As information or data that effectively rules out a particular diagnosis for a chief complaint
becomes available, remove that diagnosis from your list & focus your attention on remaining
possibilities.
6. Once a diagnosis has been confirmed, the problem list should be diagnosis-oriented ra-
ther than problem-oriented.
Pertinent Positive - ANSWER - Symptoms or signs that are present that you would ex-
pect to find if a possible cause for for a patient's problem were true, which then supports
the diagnosis.
Pertinent Negative - ANSWER Expected symptoms or signs that are not present, facts
that you would expect to find if a possible cause for a patient's problem were true, which
then weaken this diagnosis by their absence.
Principles of Good Documentation
**Checklist to Ensure a Quality Clinical Record.** - ANSWER 1. Is the organization
clear?
- Make the headings clear.
- Accent your organization with indentations and spacing.
- Arrange the HPI in chronologic order, starting with the current episode, the filling in rele-
vant background information.
2. Does the included information contribute directly to the Assessment?
3
office or hospital.
- Provides fundamental and personalized knowledge about patient.
- Strengthens the clinician-patient relationship.
- Helps identify or rule out physical causes related to patient concerns.
- Provides a baseline for future assessments.
- Creates a platform for health promotion through education and counseling.
- Develops proficiency in the skills of physical assessment.
Focused Patient Assessment - ANSWER - Appropriate for established patients, espe-
cially during routine or urgent care visits.
- Addresses focused concerns or symptoms.
- Assesses symptoms restricted to a specific body system.
- Applies examination methods relevant to assessing the concern or problem as thoroughly
and carefully as possible.
Subjective Information - ANSWER - The clinical record from the Chief Complaint (CC)
through the Review of Systems (ROS) is considered SUBJECTIVE information.
- Includes symptoms which are health concerns the patient tells the provider.
- Includes feelings, perceptions, and concerns obtained from the clinical interview.
- Examples: complaints of sore throat, headache, or pain.
Objective Information - ANSWER - All physical examination, laboratory information
and test data are objective data.
1
,Components of Comprehensive Adult Health History - ANSWER - Initial information
(Identifying patient information/source/reliability)
- Chief Complaint(s)
- History of Present Illness
- Past Medical History
- Family History
- Personal/Social History
- Review of Systems (ROS)
SNAPPS method - ANSWER - Summarize the history and findings.
- Narrow the differential diagnosis to two to three possibilities.
- Analyze the differential by comparing and contrasting the possibilities.
- Probe the preceptor by asking questions about alternative approaches or uncertainties.
- Plan the management of the patient's health issues.
- Select an issue from the case for self-directed learning.
Creating a Differential Diagnosis
*Hoofbeats = Horses NOT Zebras* - ANSWER - The differential diagnosis process in-
volves using clinical reasoning to distinguish between two or more conditions that share sim-
ilar signs and symptoms. Based on the CC the NP gathers information through PMH (subjec-
tive data) and physical examination (objective data) to establish a broad list of common &
uncommon diagnosis. As the provider collects more data, competing hypotheses are either
confirmed, disproved, or their priority changes.
Steps for Creating a Differential Diagnosis - ANSWER 1. Initially start with a broad list
of diagnoses until further information or data is obtained.
2. List your top diagnosis FIRST followed by other potential diagnoses for a specific problem
*but keep it problem oriented until you have an actual diagnosis.*
2
, 3. Aggressively prioritize work up of the most likely and most harmful (ie, life threatening)
diagnoses under consideration.
4. Prioritize the work up of ACUTE and REVERSIBLE diseases followed by CHRONIC and IRRE-
VERSIBLE (eg, delirium r/t a medical cause vs. chronic, progressive dementia).
5. As information or data that effectively rules out a particular diagnosis for a chief complaint
becomes available, remove that diagnosis from your list & focus your attention on remaining
possibilities.
6. Once a diagnosis has been confirmed, the problem list should be diagnosis-oriented ra-
ther than problem-oriented.
Pertinent Positive - ANSWER - Symptoms or signs that are present that you would ex-
pect to find if a possible cause for for a patient's problem were true, which then supports
the diagnosis.
Pertinent Negative - ANSWER Expected symptoms or signs that are not present, facts
that you would expect to find if a possible cause for a patient's problem were true, which
then weaken this diagnosis by their absence.
Principles of Good Documentation
**Checklist to Ensure a Quality Clinical Record.** - ANSWER 1. Is the organization
clear?
- Make the headings clear.
- Accent your organization with indentations and spacing.
- Arrange the HPI in chronologic order, starting with the current episode, the filling in rele-
vant background information.
2. Does the included information contribute directly to the Assessment?
3
