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2. Gordon's functional health patterns - Wikipedia

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

   The following areas are assessed through questions asked by the nurse and medical examinations to provide an overview of the individual's health status and health practices that are used to reach the current level of health or wellness. [1] [2] Health Perception and Management; Nutritional metabolic

3. SAMPLE history - Wikipedia

   en.wikipedia.org/wiki/SAMPLE_History

   It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]

4. 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.

5. History of the present illness - Wikipedia

   en.wikipedia.org/wiki/History_of_the_present_illness

   Following the chief complaint in medical history taking, a history of the present illness (abbreviated HPI) [1] (termed history of presenting complaint (HPC) in the UK) refers to a detailed interview prompted by the chief complaint or presenting symptom (for example, pain).

6. Case report form - Wikipedia

   en.wikipedia.org/wiki/Case_report_form

   A case report form (or CRF) is a paper or electronic questionnaire specifically used in clinical trial research. [1] The case report form is the tool used by the sponsor of the clinical trial to collect data from each participating patient.

7. Nursing documentation - Wikipedia

   en.wikipedia.org/wiki/Nursing_documentation

   A written record of the history, treatment, care, and response of the client while under the care of a health care provider. A guide for reimbursement of care costs. Evidence of care in a court of law. A legal record that can be used as evidence of events that occurred or treatments given. Show the use of the nursing process.