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Be aware that this is a legal document, and accurate recording is important for evaluation, insurance reimbursement, and researchEvidence-Based AssessmentoCurrent and best clinical practice based on research standards focused on systematic reviews of randomized clinical trials (RCTs)oUtilizing evidenced-based practice (EBP) in conjunction with provider experience will lead to better health outcomes for patients
oFostering a “culture of EBP” at both the undergraduate and graduate levels will assist health educators to make EBP the “gold standard” of practiceCollecting Four Types of Data oComplete total health databaseIncludes complete health history and full physical examinationDescribes current and past health state and forms baseline to measure all future changes Yields first diagnosesoEpisodic orproblem-centered databaseFor limited or short-term problemsCollect “mini” database, smaller scope and more focused than complete databaseConcerns mainly one problem, one cue complex, or one body systemHistory and examination follow direction of presenting concernoFollow-up databaseStatus of all identified problems should be evaluated at regular and appropriate intervalsNote changes that have occurred Evaluate whether problem is getting better or worseIdentify coping strategies being usedoEmergency databaseRapid collection of data, often compiled concurrently with lifesaving measuresDiagnosis must be rapid and comprehensive in natureAMPLEAllergiesMedicationsPast medical historyLast mealEvents surrounding injury
Frequency of AssessmentoInterval of assessment varies with illness and wellness needsIll people seek care because of pain or abnormal signs and symptomsThis prompts an assessment: gathering a complete, episodic, or emergency databaseScreening history for dietary intake, physical activity, tobacco/alcohol/drug use, and sexual practicesCounseling for injury prevention, substance use, sexual behavior, diet and exercise, and dental healtho