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Verified | 2026
Focused Assessment - ✔✔ANSWER ✔✔--Addresses focused concerns
or symptoms
-Used for established clients during routine or urgent care visits
-Health history and physical exams are focused on the problem
-Includes:
• brief history of the present illness
• only the system related to the problem in the review of systems
Comprehensive Assessment - ✔✔ANSWER ✔✔--Used for new clients
-Provides personalized information about the client
-Strengthens the clinician-client relationship
,-Provides a baseline for future assessments
-Provides an opportunity for health promotion education and
counseling
-Includes:
• extended history of the present illness
• at least two areas of past medical history, family history, and social
history
• at least 10 systems in the review of systems
Subjective data - ✔✔ANSWER ✔✔-includes symptoms that the client
describes such as a sore throat, headache, or pain. It also includes the
client's feelings, perceptions, and concerns
Information obtained from the client during any part of the health
history
Examples of Subjective Data:
-Lower back pain
-Fatigue
-Stomach cramps
-Immunization history
Objective data - ✔✔ANSWER ✔✔-includes the physical examination
findings or signs observed
All physical examinations, laboratory information, and test data
Examples of Objective Data:
,-Heart rate
-Blood pressure
-Lung sounds
-Wound appearance
-Ambulation description
-Weight
Clinical Encounter Sequence (detailed) - ✔✔ANSWER ✔✔-Initiate
Encounter
-Review the clinical record
-Ensure the client is comfortable
-Clarify the goals/agenda for the encounter; balance provider and client
goals
-Establish rapport
-Identify the client's preferred title, name, and gender pronouns
-Use "people first" language (i.e., a person with hearing loss, a person
who uses a wheelchair)
Gather Information
-ID the client's chief complaint or reason for seeking care
-Invite the client's story using an open-ended approach
-Gather information about the client's perspective of the illness using
the mnemonic FIFE
, -Conduct the health history interview
-Gather information about past medical history, medications and
allergies, family history, personal and social history, and ROS
Perform the Physical Exam
-Conduct the exam based on the information obtained from the health
history
-Maintain client's comfort and privacy throughout the exam
Explain and Plan
-Assess and respond to the client's needs for information
-Negotiate and make decisions together
-Utilize teach-back to ensure the client understands the plan
Close the Encounter
-Leave time for the client to ask questions
-Summarize the plans for future evaluation, treatments, and follow up
The general sequence of a clinical encounter is to: - ✔✔ANSWER ✔✔--
initiate the encounter
-gather information
-perform a physical exam
-develop a shared plan