A Standards-Based Approach for Quality Assessment in Data Collection for Retrospective Clinical Studies

Evangelia Minga1,2, Christina Papangelou1, Thomas Chatzikonstantinou1

  • 1Institute of Applied Biosciences, Center for Research and Technology Hellas, Thessaloniki, Greece.

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The nursing history captures and records the patient's health status, so that a care plan evolves to meet the patient's individual needs. The nursing health history is a part of the initial assessment. A comprehensive history covers all health dimensions and plays a significant role in the assessment process. A comprehensive history includes the patient's biographical information, reasons for seeking health care, expectations, present and past health history, medications, and...
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The physical assessment examines the patient for objective data that defines the patient's condition, and aids in formulating the nursing care plan. The purpose of physical assessment is a health status appraisal, which includes identifying health problems, and establishing a database for nursing intervention.
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