Subjective Data Collection: 50 of 50 (100.0%)
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...
Subjective Data Collection: 50 of 50 (100.0%)
Curr
ent
Heal
th
Stat
us
Psyc
hoso
cial
Hist
ory
Soci
al
Dete
rmin
ants
of
Heal
th
Ment
al
Heal
th
Revi
ew
of
Syst
ems
Indicates an item that you
found.
Indicates an item that is
available to be found.
Categ
ory
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.
Confirmed reason for visit Reports needing a pre-employment physical
Reports no current acute health problems
Asked about last visit to a healthcare provider Last visit to a healthcare provider was 4 months
ago
Reason for last visit was annual gynecological
exam
Last general physical examination was 5 months
ago when she was prescribed metformin and daily
inhaler
Asked about current prescription medications Reports taking diabetes medication
Reports using a daily inhaler
Reports taking prescription birth control pills
Followed up about diabetes medication Medication is metformin
Started taking metformin 5 months ago
Reports that eating probiotic yogurt helps with side
effects and they have abated over time
Followed up on metformin frequency and dose Reports taking metformin twice daily
Metformin dose is 850 mg
Asked about asthma medication Reports using Flovent inhaler twice daily
Has a Proventil rescue inhaler
Last use of Proventil inhaler was three months ago
Has used Proventil inhaler twice in the last year
Followed up about birth control prescription Started taking birth control 4 months ago
Reason for birth control was to manage PCOS
symptoms
Birth control type is Yaz (drospirenone and ethinyl
estradiol)
Takes birth control pill daily
Takes birth control pill at the same time every day
Reports no skipped days
Asked about current non-prescription
medications
Reports rare Advil use for cramps
Reports no OTC herbal products
Reports no OTC vitamins
Reports no OTC supplements
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