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Open-ended questions are those that cannot be answered with a simple "yes" or "no" response. If the person is unable to respond, then family or caregivers will be given the opportunity to answer the questions. [3] The typical nursing assessment in the clinical setting will be the collection of data about the following:
A health assessment is a plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history. It is done to detect diseases early in people that ...
The routine physical, also known as general medical examination, periodic health evaluation, annual physical, comprehensive medical exam, general health check, preventive health examination, medical check-up, or simply medical, is a physical examination performed on an asymptomatic patient for medical screening purposes.
An examination (exam or evaluation) or test is an educational assessment intended to measure a test-taker's knowledge, skill, aptitude, physical fitness, or classification in many other topics (e.g., beliefs). [1] A test may be administered verbally, on paper, on a computer, or in a predetermined area that requires a test taker to demonstrate ...
A health risk assessment (HRA) is a health questionnaire, used to provide individuals with an evaluation of their health risks and quality of life. [5] Commonly a HRA incorporates three key elements – an extended questionnaire, a risk calculation or score, and some form of feedback, i.e. face-to-face with a health advisor or an automatic online report.
An abdominal examination is a portion of the physical examination which a physician or nurse uses to clinically observe the abdomen of a patient for signs of disease. The abdominal examination is conventionally split into four different stages: first, inspection of the patient and the visible characteristics of their abdomen.
The cardiovascular examination is a portion of the physical examination that involves evaluation of the cardiovascular system. The exact contents of the examination will vary depending on the presenting complaint but a complete examination will involve the heart (cardiac examination), lungs (pulmonary examination), belly (abdominal examination) and the blood vessels (peripheral vascular ...
The assessment and plan (abbreviated A/P" [1] or A&P) is a component of an admission note. Assessment includes a discussion of the differential diagnosis and supporting history and exam findings. The plan is typically broken out by problem or system. Each problem should include: brief summary of the problem, perhaps including what has been done ...