NR 509 ABDOMINAL PAIN DOCUMENTATION SHADOW HEALTH - MS. ESTHER PARK NOTES

NR 509 ABDOMINAL PAIN
DOCUMENTATION SHADOW
HEALTH - MS. ESTHER PARK
NOTES




Orientation +1 - correct answers--Please verify your name and birthday

Chief Complaint +1 - correct answers--Do you have any pain today?

History of Presenting Illness +1 - correct answers--Can you rate your current pain level
on a scale of 0-10?

, History of Presenting Illness +1 - correct answers--Where is your pain?

History of Presenting Illness +1 - correct answers--Can you describe your pain?

History of Presenting Illness +1 - correct answers--Does anything make your pain any
better?

History of Presenting Illness +2 - correct answers--Does anything make your pain
worse?

History of Presenting Illness +1 - correct answers--Have you taken anything for your
pain?

History of Presenting Illness +1 - correct answers--When did you first notice the pain?

Social History +1 - correct answers--What was the last thing you ate?

History of Presenting Illness +1 - correct answers--Do you have difficulty going to the
bathroom?

History of Presenting Illness +2 - correct answers--How often do you go to the
bathroom?

Past Medical History +1 - correct answers--How is your diet?

Home Medications +1 - correct answers--Do you take any medications?

Home Medications +1 - correct answers--Do you take any antibiotics?

Social History +1 - correct answers--Do you eat a lot of fiber?

Review of Symptoms +1 - correct answers--How many meals a day do you eat?

Past Medical History +1 - correct answers--Have you ever had abdominal surgery?

Review of Systems +1 - correct answers--How many times do you urinate?

Social History +1 - correct answers--Do you have trouble walking?

Social History +1 - correct answers--Do you live alone?

Social History +1 - correct answers--Do you drink alcohol?

Auscultate- Abdominal Arteries - correct answers--All are no bruit