Be aware that this is a legal document and accurate recording is important for

Be aware that this is a legal document and accurate

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Be aware that this is a legal document, and accurate recording is important for evaluation, insurance reimbursement, and research Evidence-Based Assessment o Current and best clinical practice based on research standards focused on systematic reviews of randomized clinical trials (RCTs) o Utilizing evidenced-based practice (EBP) in conjunction with provider experience will lead to better health outcomes for patients
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o Fostering a “culture of EBP” at both the undergraduate and graduate levels will assist health educators to make EBP the “gold standard” of practice Collecting Four Types of Data o Complete total health database Includes complete health history and full physical examination Describes current and past health state and forms baseline to measure all future changes Yields first diagnoses o Episodic or problem-centered database For limited or short-term problems Collect “mini” database, smaller scope and more focused than complete database Concerns mainly one problem, one cue complex, or one body system History and examination follow direction of presenting concern o Follow-up database Status of all identified problems should be evaluated at regular and appropriate intervals Note changes that have occurred Evaluate whether problem is getting better or worse Identify coping strategies being used o Emergency database Rapid collection of data, often compiled concurrently with lifesaving measures Diagnosis must be rapid and comprehensive in nature AMPLE A llergies M edications P ast medical history L ast meal E vents surrounding injury
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Frequency of Assessment o Interval of assessment varies with illness and wellness needs Ill people seek care because of pain or abnormal signs and symptoms This prompts an assessment: gathering a complete, episodic, or emergency database Screening history for dietary intake, physical activity, tobacco/alcohol/drug use, and sexual practices Counseling for injury prevention, substance use, sexual behavior, diet and exercise, and dental health o
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