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2. Nursing assessment - Wikipedia

   en.wikipedia.org/wiki/Nursing_assessment

   Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides.

3. Gordon's functional health patterns - Wikipedia

   en.wikipedia.org/wiki/Gordon's_functional_health...

   Cognitive-perceptual-assessment of neurological function is done to assess, check the person's ability to comprehend information; Self perception/self concept; Role relationship—This pattern should only be used if it is appropriate for the patient's age and specific situation. Sexual reproductivity; Coping-stress tolerance; Value-Belief Pattern

4. Admission note - Wikipedia

   en.wikipedia.org/wiki/Admission_note

   see Physical examination#Example: labs and diagnostics studies "none" May cover studies performed at an outside hospital, during prior admissions, or in the ER before the current admission. assessment and plan (A&P) "Pt is a 30 yo female..." Assessment and plan are very closely related, and are often reported in a single section.

5. GALS screen - Wikipedia

   en.wikipedia.org/wiki/GALS_screen

   • The pGALS assessment is a simple evidence-based approach to musculoskeletal assessment based on the adult GALS (Gait, Arms, Legs, Spine) screen and has been shown to have high sensitivity to detect significant abnormalities • pGALS is primarily aimed at the school aged child, but younger children will often comply with pGALS, especially ...

6. Progress note - Wikipedia

   en.wikipedia.org/wiki/Progress_note

   Progress Notes are the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. [1]

7. SOAP note - Wikipedia

   en.wikipedia.org/wiki/SOAP_note

   The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.

8. Objective structured clinical examination - Wikipedia

   en.wikipedia.org/wiki/Objective_structured...

   An objective structured clinical examination (OSCE) is an approach to the assessment of clinical competence in which the components are assessed in a planned or structured way with attention being paid to the objectivity of the examination which is basically an organization framework consisting of multiple stations around which students rotate and at which students perform and are assessed on ...

9. Health assessment - Wikipedia

   en.wikipedia.org/wiki/Health_assessment

   Health assessment has been separated by authors from physical assessment to include the focus on health occurring on a continuum as a fundamental teaching. [8] In the healthcare industry it is understood health occurs on a continuum, so the term used is assessment but may be preference by the speciality's focus such as nursing, physical therapy, etc.