EMR and Med Therapeutics-Obtaining Med History and VS

previous medical conditions and events for a patient

• world history

• medical history

something that can be observed or measured when assessing a patient

• sign

• symptom

something the patient complains of or describes during the secondary assessment

• symptom

• sign

the main medical complaint as described by the patient

• chief complaint

• medical history

an acronym used to obtain a patient history during the secondary assessment

• SAMPLE

• OPQRST

a mnemonic used during a secondary assessment to help assess a patient's chief complain

• SAMPLE

• OPQRST

the most common signs used to evaluate a patient's condition

• vital signs

• mental status

the general condition of a patient's level of consciousness and awareness

• mental status

• vital signs

the adequate delivery of well-oxygenated blood and nutrients to all parts of the body, and the elimination of waste products

• capillary refill

• perfusion

the act of comparing multiple sets of signs and symptoms over time to determine if the patient's condition is worsening, improving, or remaining the same

• trending

• baseline vital signs