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Chief Complaint Primary reason the patient states they came to the clinic to be seen by a medical provider Etiology Cellular level explanation of a disease or disorder Pathophysiology Cause of the underlying disease or disorder, can also be the pathophysiology Subjective HPI Patient explanations and definitions of their chief complaint Symptoms or Problems The patient list of all of their the physical or psychological issues that result from their disorders or diseases Assessment Medical provider diagnose(s) of the patient’s condition Plan Treatment or interventions the medical provider recommends to manage the diseases or disorders VINDICATE An extensive list of ALL possible medical diagnoses a patient could have with the symptoms that they present with Review of Systems (ROS) List of all the possible medical questions of each body system to ask the patient from their head to their toe Focused physical examination The limited examination done by the medical provider that is specific to the body systems the patient or provider have found disorders; Complete physical examination The head to toe full physical examination of a patient including all body systems Point of care findings Labs or diagnostic tests done at the clinic with quick results and not done
SCIENCE
HEALTH SCIENCE
NURSING
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