Health History/POC Flashcards
The First 6 standards are based on the nursing process
Assessment
Diagnosis
outcome identification
Planning
Implementation
Evaluation
Assessment
Collection of “pertinent data and information relative to the healthcare consumer’s health or the situation
5 core competencies identified by Institute of Medicine
1) Provide patient-centered care
2)Work in interdisciplinary teams
3) Use evidenced-based practice
4) Apply quality improvements
5) Use informatics
ADOPIE
Assessment
Diagnosis
Outcome Identification
Planning
Implementation
Evaluation
Assessment
Collects pertinent data & information relative to pt’s health or the situation
Diagnosis
Analyzes the assessment data to determine actual or potential diagnosis, problems, or issues
Outcome Identification
Identifies expected outcomes for plan individualized to the pt or situation
Planning
Develops a plan that prescribes strategies to attain expected, measurable outcomes
Implementation
Implements the identified plan
* Coordination of Care- Coordinates care delivery
** Health teaching and Health Promotion- Uses strategies ot promote health and a safe environment
Evaluation
Evaluates progress toward attainment of goals and outcomes
Types of Health Assessments
Comprehensive assessment
Problem-based/focused assessment
Episodic/follow up assessment
Shift assessment
Screening assessment/examination
Comprehensive Assessment
Detailed history and physical exam performed at the onset of care in a primary care setting or on admission to a hospital or LTC facility.
Includes health problems experienced by the patient, health promotion, disease prevention and assessment for problems associated with known risk factors or assessment for age and gender specific health problems
Problem-Based/focused assessment
H & P examination, that is limited to a specific problem or complaint. Commonly used in a walk in clinic/ER, may slo be applied in other outpatient setting.
Collecting data on a specific problem, the nurse also considers the potential impact of the patient’s underlying health status
Episodic/Follow up assessment
usually done when a patient is following up with a health are profider for a previously identified problem
Shift Assessment
When individuals are hospitalized nurse conduct assessment each shift. The purpose of the shift assessment identify changes to a patients condition from the baseline-Focus based on the condition or problem the patient is experiencing
Screening assessment/examination
Short examination focused on disease detection. Maybe performed in a health care providers office as part of the comprehensive exam
or at a health fair
Examples include B/P screening, glucose screening, cholesterol screening, and colorectal screening
Health History
Subjective data collected during interview involving nurse & patient
Purpose to obtain important information from patient for a plan to:
Promote Health
Prevent Disease
Resolve acute health problems
Minimize limitation r/t chronic health problems can be developed
Health History Components
Biographic data
Reason for seeking care
H/x of presenting illness
Present health status
Past health h/x
Family h/x
Personal/Psychosocial h/x
Review of systems
