Term
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Definition
| (history) what patient says about himself or herself during history taking |
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Term
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Definition
| (physical exam) Observed when inspecting, percussing, palpating, and auscultating patient during physical examination |
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Term
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Definition
| Formed from these elements, plus patient’s record and laboratory studies |
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Term
| Clinical Reasoning Models |
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Definition
-Diagnostic reasoning
-Critical thinking and diagnostic process |
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Term
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Definition
-attend to initially available cues
-formulate diagnostic hypotheses
-gather data relative to tentative hypothesis
-evaluate each hypothesis w/new data collected to arrive @ final diagnosis |
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Term
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Definition
-assessment
-diagnosis
-outcome identification
-planning
-implementation
-evaluation |
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Term
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Definition
collect data
-review of clinical record
-interview
-health history
-physical examination
-functional assessment
-cultural and spiritual assessment
-consultation
-review of the literature |
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Term
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Definition
-interpret data
-validate inferences
-compare clusters of cues
-identify related factors
-document the diagnosis |
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Term
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Definition
-identify expected outcomes
-individualize to patient
ensure outcomes are realistic & measurable
-include a time frame |
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Term
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Definition
-esta. priorities
-develop outcomes
-set time frames for outcomes
-identify interventions
-document plan of care |
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Term
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Definition
-Determine patient readiness
-Review planned interventions
-Collaborate with other team members
-Supervise by delegating appropriate responsibilities
-Counsel person and significant others
-Involve person in health care
-Refer for continuing care
-Document care provided |
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