What to look for? How to look
for it? What to document and how?
In many cases, the
clinician will recognize a familiar starting point for beginning a particular
clinical encounter. Some of these are listed to the left. Click relevant headings on
this list to display some hints and suggestions.
Remember to think about the
following as you carry out your clinical assessments:
- Disease
->Impairments->Disabilities->Coping & Sequelae
- Symptoms: positive (e.g.,
seizure) or negative (e.g., weakness)
- Signs: focal, multifocal,
diffuse, remote
- Standardized tests, scales,
& scores
- Classifications
- Comfort
- Safety
- Capacity
- Response to management
- Concurrent health status
- Diagnosis components:
etiology, pathology, anatomy, physiology, classification, time factors.