Shadowhealth Health History Subjective

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Shadowhealth Health History Subjective Subjective Data Collection: 88 of 88 (100.0%) Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips... and Example Questions. Found: Indicates an item that you found. Available: Indicates an item that is available to be found. Category Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Patient Data Not Scored A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. History of Presenting Illness: Foot Wound Finding: Established chief complaint Finding: Reports pain (Found)Pro Tip: Beginning your conversation with your patient by asking an open-ended question is a best practice for gauging your patient's general condition.Example Question:How severe is the pain? Finding: Reports open foot wound (Found)Pro Tip: If a patient mentions pain, it's important to determine what specifically is causing her pain.Example Question:What's causing your pain? Finding: Asked to rate pain on a scale Finding: Rates present pain at a 7 out of 10 (Found)Pro Tip: Asking your patient to rate her pain on a scale of 0 to 10 is important to gauge how it ebbs and flows while she is in your care.Example Question:Can you rate the pain on a scale of 0 to 10? Finding: Asked for details about the pain Finding: Describes the pain as throbbing (Found)Pro Tip: Determining how your patient describes the characteristics of the pain can be important data to support the cause of the pain.Example Question:Can you please describe the pain? Finding: Describes the pain as sharp when she attempts to stand (Found)Pro Tip: Determining how your patient describes the characteristics of the pain can be important data to support the cause of the pain.Example Question:What is the pain like when you stand on your foot? Finding: Initial injury occurred 1 week ago (Found)Pro Tip: Discovering how long ago the pain began is the first step in understanding whether the pain is chronic or acute.Example Question:When did the pain start? Finding: Pain has increased in the past 2 days (Found)Pro Tip: Finding out how the patient's pain has changed will give you insight into the acceleration of infection.Example Question:How has the pain changed over time? Finding: Reports feeling pain radiating into ankle (Found)Pro Tip: Asking about where else the patient's pain radiates can help determine the progression of infection.Example Question:Does the pain radiate anywhere else? Finding: Pain prevents bearing weight on foot (Found)Pro Tip: Determining if your patient can bear weight on an injury is important to determine their risk for falls while in your care.Example Question:Can you bear weight on your foot? Finding: Clarified location of wound Finding: Confirmed that right foot is injured (Found)Pro Tip: Confirming which extremity an injury is located is a best practice for your patient's safety.Example Question:Which foot is in pain? Finding: Confirmed that wound is on the plantar surface of her foot (Found)Pro Tip: Confirming where a wound is located ensures you are aware of your patient's biggest complaint.Example Question:Where is the wound? Finding: Determined details of the injury Finding: Scraped foot on bottom rung of a step stool (Found)Pro Tip: Discovering how an injury happened helps to assess your patient's risk factors for injury.Example Question:How did your injury happen? Finding: Reports no other injuries besides foot wound (Found)Pro Tip: Discovering additional injuries can reveal more information about the circumstances that caused the presenting injury.Example Question:Did you injure anything besides your foot? Finding: Was not drinking at the time of the injury (Found)Pro Tip: Finding out if alcohol is involved in an injury can give you insight into a patient's potential substance abuse, and can uncover aggravating factors.Example Question:Did you have any alcoholic drinks before your injury? Finding: Was not wearing shoes at the time of injury (Found)Pro Tip: Asking about clothing, footwear, and other protective elements ...........................................CONTINUED.................................... [Show More]

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