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  2. 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]

  3. OPQRST - Wikipedia

    en.wikipedia.org/wiki/OPQRST

    Each letter stands for an important line of questioning for the patient assessment. [ 3 ] [ 4 ] This is usually taken along with vital signs and the SAMPLE history and would usually be recorded by the person delivering the aid, such as in the "Subjective" portion of a SOAP note , for later reference.

  4. Patient-Reported Outcomes Measurement Information System

    en.wikipedia.org/wiki/Patient-Reported_Outcomes...

    The Patient-Reported Outcomes Measurement Information System [1] (PROMIS) provides clinicians and researchers access to reliable, valid, and flexible measures of health status that assess physical, mental, and social well–being from the patient perspective. PROMIS measures are standardized, allowing for assessment of many patient-reported ...

  5. List of open-source health software - Wikipedia

    en.wikipedia.org/wiki/List_of_open-source_health...

    Nightscout is a collection of software tools, including mobile clients, to enable DIY cloud-based continuous glucose monitoring "…for informational and educational purposes." [ 31 ] Individual components are available under various open-source licenses, including the GNU GPL , [ 32 ] GNU AGPL , [ 33 ] MIT License , [ 34 ] and BSD licenses .

  6. Nursing assessment - Wikipedia

    en.wikipedia.org/wiki/Nursing_assessment

    Other assessment tools may focus on a specific aspect of the patient's care. For example, the Waterlow score and the Braden scale deals with a patient's risk of developing a Pressure ulcer (decubitus ulcer), the Glasgow Coma Scale measures the conscious state of a person, and various pain scales exist to assess the "fifth vital sign".

  7. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    A medical diagnosis for the purpose of the medical visit on the given date of the note written is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely. The assessment will also include possible and likely etiologies of ...

  8. Patient Health Questionnaire - Wikipedia

    en.wikipedia.org/wiki/Patient_Health_Questionnaire

    The Patient Health Questionnaire 2 item (PHQ-2) is an ultra-brief screening instrument containing the first two questions from the PHQ-9. [ 8 ] : 3 Two screening questions to assess the presence of a depressed mood and a loss of interest or pleasure in routine activities , and a positive response to either question indicates further testing is ...

  9. Personal health record - Wikipedia

    en.wikipedia.org/wiki/Personal_health_record

    The term "personal health record" is not new. The term was used as early as June 1978, [2] and in 1956, there was a reference was made to a "personal health log." [3] The term "PHR" may be applied to both paper-based and computerized systems; [4] usage in the late 2010s usually implies an electronic application used to collect and store health data.