Clinical assessment
Clinical assessment is the systematic evaluation of a person’s symptoms, history, functioning, and context to guide diagnosis and care.
Clinical interview: A structured or open-ended conversation used to gather health information and understand a person’s concerns. It elicits symptoms, history, goals, and context directly from the person.
Signs and symptoms: Symptoms are experiences reported by a person; signs are observable or measurable findings. Assessment distinguishes reported experiences from findings others can verify.
Triage: The prioritization of people for care according to urgency and available resources. Rapid assessment identifies who needs immediate attention.
Medical diagnosis: The identification of a disease or condition based on clinical evidence. Assessment gathers and interprets evidence; diagnosis names a condition when justified.
Physical examination: The hands-on and observational evaluation of the body performed by a health professional. Its findings complement reported symptoms with observable signs.
Medical history: A record of a person’s past and current health conditions, treatments, and relevant family history. Past illness and treatment can change the meaning of current complaints.
Psychological assessment: The systematic evaluation of psychological symptoms, abilities, and behavior using interviews, observations, and measures. It applies assessment methods to mental and behavioral concerns.
Screening: The testing of people without recognized symptoms to identify those at elevated risk of a condition. Screening is narrower and precedes the fuller evaluation of a suspected problem.
Mental status examination: A structured description of a person’s current appearance, behavior, mood, thinking, perception, and cognition. It organizes observations of mental functioning during an encounter.
Functional status: A description of how well a person performs daily activities and participates in life roles. Function shows how health concerns affect everyday life beyond symptom counts.