CLINICAL DECISION GUIDE
◉Assessment . Answer: Interview, health history, ROS, physical
examination, functional assessment, spiritual and cultural
assessment
◉Subjective data . Answer: What patient SAYS
◉Objective data . Answer: What you OBSERVE
◉SMART component in outcome identification . Answer: Specific
Measurable
Attainable
Relevant
Time bound
◉First level priority . Answer: Emergent situations, life threading
and needs immediate attention
, ◉Second level priority . Answer: Requires attention to avoid further
deterioration
◉Third level priorirty . Answer: Can be addressed after more
important problems are addressed
◉Complete total health Database . Answer: Full health history, and
physical exam
Yields first diagnosis
Current and past health state
◉Focused or problem centered database . Answer: Limited and
short term problems
Concerned with mainly one problem, or one body system
◉Follow up database . Answer: Follow up care to evaluate if problem
is getting better or worse
◉Emergency database . Answer: Rapid urgent collection of data
Radio diagnosis
◉Primary prevention . Answer: Preventing health problems
Ex: vaccines, safety glasses