| Term | Meaning |
|---|
| Actual (A) | The problem is present now and can be seen or measured; evidenced by signs and symptoms. |
| Risk (R) | The problem has not happened yet but risk factors are present; never supported by signs of the problem. |
| PES | Problem – Etiology (cause) – Evidence (signs/symptoms): the pattern for writing a diagnosis. |
| SMART goal | Specific, Measurable, Achievable, Relevant, Time-bound. Who, what change, how much, by when. |
| Subjective (S) | What the patient or family says. |
| Objective (O) | What you observe and measure. |
| ABC / ABCDE | Airway, Breathing, Circulation (Disability, Exposure) — the order of priority in an emergency. |
| SBAR | Situation, Background, Assessment, Recommendation — structured way to escalate. |
| Teach-back | Asking the patient to explain in their own words to confirm understanding. |
| NEWS2 | National Early Warning Score — validated track-and-trigger score for adults. |
| SpO₂ | Oxygen saturation measured by pulse oximetry. |
| MUST | Malnutrition Universal Screening Tool. |
| Bristol Stool Chart | Seven-type visual scale of stool form. |
| NRS 0–10 | Numeric rating scale for pain. |
| FLACC | Face, Legs, Activity, Cry, Consolability — behavioural pain scale for young children. |
| PAINAD | Pain Assessment in Advanced Dementia. |
| Morse Fall Scale | Validated fall-risk scale. |
| Braden Scale | Validated pressure-injury risk scale. |
| TIME | Tissue, Infection/Inflammation, Moisture, Edge — wound bed assessment. |
| Barthel Index / Katz ADL | Scales of independence in activities of daily living. |
| PHQ-9 / GAD-7 | Screening questionnaires for depression / anxiety. |
| C-SSRS | Columbia Suicide Severity Rating Scale. |
| MEOWS | Modified Early Obstetric Warning Score. |
| APGAR | Newborn score: Appearance, Pulse, Grimace, Activity, Respiration. |
| PEWS | Paediatric Early Warning Score. |
| 4AT / CAM | Rapid delirium screening tools. |
| Mini-Cog | Brief cognitive screening test. |
| RASS | Richmond Agitation-Sedation Scale. |
| CPOT | Critical-Care Pain Observation Tool. |
| Aldrete | Post-anaesthesia recovery score. |
| GCS | Glasgow Coma Scale. |
| NIHSS | NIH Stroke Scale. |
| qSOFA | Quick Sepsis-related Organ Failure Assessment. |
| ESAS | Edmonton Symptom Assessment System. |
| FICA | Faith, Importance, Community, Address — spiritual history tool. |
| PLISSIT | Permission, Limited Information, Specific Suggestions, Intensive Therapy — sexual health model. |