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In a physical examination, medical examination, clinical examination, or medical checkup, a medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. It generally consists of a series of questions about the patient's medical history followed by an examination based on the reported symptoms.
a physical examination of a patient: [1] [2] This varies based on the purpose of the interview. explaining results and planning: [1] [2] This aims to ensure a shared understanding, and allowing for shared decision-making. [1] closing a session: [1] [2] This may involve discussing further plans. [1]
The patient history and interview is considered to be subjective but still of high importance when combined with objective measurements. High quality interviewing strategies include the use of open-ended questions. Open-ended questions are those that cannot be answered with a simple "yes" or "no" response.
There are many areas where patient education can improve the outcomes of treatment. For example, in patients with amputations, patient education has been shown to be effective when approached from all angles by the healthcare team (nurse, primary care physician, prosthetist, physical therapist, occupational therapist etc.).
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care. [1]
The objective section of the SOAP includes information that the healthcare provider observes or measures from the patient's current presentation, such as: Vital signs are often already included in the chart. However, it is an important component of the SOAP note as well. [13] Vital signs and measurements, such as weight.
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 ...
The physical examination is the recording of observations of the patient. This includes the vital signs , muscle power and examination of the different organ systems, especially ones that might directly be responsible for the symptoms the patient is experiencing.