Assessment is the process of gathering a comprehensive database about the client's present, past, and potential health problems, as well as a description of the client as a whole in his or her environment. It includes a comprehensive nursing history, a physical examination, and laboratory/x-ray data, and it concludes with the formulation of nursing diagnoses.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) strengthened the privacy protections for consumers. Communications are confidential, and the client needs to give permission for other family members to remain in the room—particularly when asking sensitive questions on pregnancies, abortions, drug use, or multiple sex partners (see Chapter 3. Safe, Effective Care Environment, Safe, Effective Care Environment).