collecting four types of data Flashcards
what are the four different types of databases that an examiner needs to establish depending on the clinical situation
complete, focused, or problem centered, follow-up, and emergency
what does the complete total health database include
a complete health history and a full physical examination
what does the complete total health database describe
current and past health state and forms baseline to measure all future changes
where is the complete total health database often collected
primary care setting
ex: pediatric or family practice clinic
independent or group private practice
college health service
women’s health care agency
visiting nurse agency
community health agency
when you work in a primary care setting what responsibilities do you have
you are the first health professional to see the patient and have primary responsibility for monitoring the person’s health care.
what do you have the opportunity of doing when collecting a complete database
opportunity to build and strengthen your relationship with the patient.
for a well person what must a complete database include
describe the person’s health state;
perception of health;
strengths or assets such as health maintenance behaviors
individual coping patterns
support systems
current developmental tasks
any risk factors or lifestyle changes
for an ill person what must a complete database include
description of the person’s health problems, perception of illness, and response to the problems.
for both a well and ill person what must a complete database screen for
screen for pathology and determine the ways people respond to that pathology or to any health problem.
why must you screen for pathology in a complete database
because you are the first, and often the only, health professional to see the patient.
This factor is important because it provides additional information about the person that leads to nursing diagnoses.
why is screening for pathology in a complete database important
This screening is important to make appropriate referrals, help the patient make health care decisions, and perform appropriate treatments
what does the complete health database note
the responses to health problems
why is noting the responses to health problems in the complete health database an important factor
it provides additional information about the person that leads to nursing diagnoses.
in acute hospital care when is the complete health database gathered
on admission to the hospital
who may collect data related specifically to pathology in the hospital
admitting physician
