NR569 Differential Diagnosis in Acute Care Final Study Guide
Comprehensive Patient Assessment
- 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
- Appropriate for established patients, especially 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
- 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
- All physical examination, laboratory information and test data are objective data.
Components of Comprehensive Adult Health History
- 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
- Summarize the history and findings.