Clinical Findings include signs—things
you can see; symptoms—things your patient
tells you about; and test results. Each
clinical finding listed in DATA has its
own page that describes what a sign, symptom,
or test result means, as well as ways you
can test for that finding.
As you work, remember that a clinical finding might not always be phrased exactly as you're thinking about it. You may need to be creative and think about different ways to say the same thing.
Example: Your patient has a large bruise
on her leg, but you don't see an entry
called bruise. What are some other ways
to describe what you have seen? Are there
other words for bruising? You may find
the symptom listed as Skin Discoloration-bruising
or Contusion (bruising).
|