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  2. Health assessment - Wikipedia

    en.wikipedia.org/wiki/Health_assessment

    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 ...

  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. Physical examination - Wikipedia

    en.wikipedia.org/wiki/Physical_examination

    The medical history and physical examination were supremely important to diagnosis before advanced health technology was developed, and even today, despite advances in medical imaging and molecular medical tests, the history and physical remain indispensable steps in evaluating any patient. Before the 19th century, the history and physical ...

  5. Medical history - Wikipedia

    en.wikipedia.org/wiki/Medical_history

    Medical history taking may also be impaired by various factors impeding a proper doctor-patient relationship, such as transitions to physicians that are unfamiliar to the patient. History taking of issues related to sexual or reproductive medicine may be inhibited by a reluctance of the patient to disclose intimate or uncomfortable information.

  6. OPQRST - Wikipedia

    en.wikipedia.org/wiki/OPQRST

    This may also be assessed for pain now, compared to pain at time of onset, or pain on movement. There are alternative assessment methods for pain, which can be used where a patient is unable to vocalise a score. One such method is the Wong-Baker faces pain scale. Time (history)

  7. Nursing assessment - Wikipedia

    en.wikipedia.org/wiki/Nursing_assessment

    Assessment of cognitive function, checking for hallucinations and delusions, measuring concentration levels, and inquiring into the client's hobbies and interests constitute an intellectual health assessment. Emotional health is assessed by observing and inquiring about how the client feels and what he does in response to these feelings.

  8. Independent medical examination - Wikipedia

    en.wikipedia.org/wiki/Independent_medical...

    An independent medical examination may be conducted at the behest of an employer or an insurance carrier to obtain an independent opinion of the clinical status of the individual. Workers' compensation insurance carriers, auto insurance carriers, and self-insured employers have a legal right to this request. Should the doctor/therapist ...

  9. 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.