NR548 WEEK 4
1 of 31
Term
Severity of the Symptoms
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"Does anything make it worse?"
"Does anything make it better?"
, How long have you been feeling this way?
Did something happen in your life that may have triggered these
emotions? How is this current situation impacting your life?
"How bothersome is this problem?"
Don't know?
2 of 31
Term
Pertinent negatives
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symptoms that are expected with a potential diagnosis related to
the chief complaint.
symptoms the client does not have that are expected with
a potential diagnosis related to the chief complaint.
should include an opening statement, a characterization of the chief
complaint in chronological order, pertinent positive symptoms,
pertinent negative symptoms, and other relevant information from
the history.
is a concise, clear, and chronological description of the chief complaint
which prompted the client's visit. a symptom analysis guided by the
mnemonic
"oldcarts" will reveal information regarding the onset, location, duration,
characteristics, aggravating factors, relieving factors, treatments, and
severity of the symptoms.
, Don't know?
3 of 31
Definition
Document information about the client's parents,
grandparents,
siblings, children, and grandchildren regarding their age,
health, and cause of death. Include whether they have
conditions such as
hypertension, coronary artery disease, stroke, diabetes, or
cancer.
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family history health maintenance
gender age
Don't know?
4 of 31
Definition
Document immunizations and screening tests such as pap
smears, mammograms, or colonoscopies. Include the
results and dates of screening tests.
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1 of 31
Term
Severity of the Symptoms
Give this one a try later!
"Does anything make it worse?"
"Does anything make it better?"
, How long have you been feeling this way?
Did something happen in your life that may have triggered these
emotions? How is this current situation impacting your life?
"How bothersome is this problem?"
Don't know?
2 of 31
Term
Pertinent negatives
Give this one a try later!
symptoms that are expected with a potential diagnosis related to
the chief complaint.
symptoms the client does not have that are expected with
a potential diagnosis related to the chief complaint.
should include an opening statement, a characterization of the chief
complaint in chronological order, pertinent positive symptoms,
pertinent negative symptoms, and other relevant information from
the history.
is a concise, clear, and chronological description of the chief complaint
which prompted the client's visit. a symptom analysis guided by the
mnemonic
"oldcarts" will reveal information regarding the onset, location, duration,
characteristics, aggravating factors, relieving factors, treatments, and
severity of the symptoms.
, Don't know?
3 of 31
Definition
Document information about the client's parents,
grandparents,
siblings, children, and grandchildren regarding their age,
health, and cause of death. Include whether they have
conditions such as
hypertension, coronary artery disease, stroke, diabetes, or
cancer.
Give this one a try later!
family history health maintenance
gender age
Don't know?
4 of 31
Definition
Document immunizations and screening tests such as pap
smears, mammograms, or colonoscopies. Include the
results and dates of screening tests.
Give this one a try later!
