What should be included in a thorough patient assessment?

A thorough patient assessment serves as the foundation for effective nursing care and encompasses a comprehensive review of the patient's health status. This includes both the medical history and a physical examination, which are crucial for understanding the patient's overall health, identifying potential health issues, and developing an appropriate care plan.

The medical history provides valuable insights into past medical conditions, surgeries, allergies, and family health issues, which can influence current health and treatment options. The physical examination allows the healthcare provider to assess the patient's current physical condition, identify any abnormalities, and monitor vital signs that inform further interventions.

In the context of patient care, neither focusing solely on current medications nor laboratory test results offers enough information to form a complete picture of a patient’s health. While those elements are important components of assessments, they should be part of a broader evaluation that also considers patient history and physical findings. Additionally, including patient preferences in treatment discussions falls into the communication domain, which is vital but is not what makes up the core of a thorough assessment.