CASES AND CORRECT ANSWERS
Student: Can you tell me about your father's health?
Tina Jones: He had high blood pressure and cholesterol. And diabetes -- we have diabetes in
common.
Student: I can't even imagine how you feel about losing your father
Tina Jones: Thanks.
Student: Tell me about your father.
Tina Jones: Dad was a little stricter than Mom growing up. . . he would sometimes get kind of
mad at us when we did something wrong. But he never hit us or anything. He would just get
really calm and quiet and tell us to go to our rooms without supper, or that we were grounded
when we were older. Or like, he'd make us rake the yard or wash his car or something. It's pretty
sad to
Student: How old was your father when he died?
Tina Jones: Last year when Dad passed, he was only 58.
Subjective Data Collection - Checklist:
Chief Complaint
,Finding: Established chief complaint
Finding: Reports pain (Found)Pro Tip: Initially establishing a chief complaint allows the patient
to express their reason for seeking care, primary concerns, or condition they are presenting
with.
Example Question: Do you have any pain?
Finding: Reports foot wound (Found)Pro Tip: If a patient mentions pain, it's important to
determine what specifically is causing her pain, if she knows.
Example Question: What's causing your pain?
History of Presenting Illness
Finding: Asked to rate current pain level on a scale
Finding: Reports current pain is 7/10 (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: Reports pain is 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: Reports pain is sharp when she attempts to stand (Found)Pro Tip: Determining what
physical activities and movements exacerbate the patient's pain can help you better understand
the problems and assess treatment needs. This can also alert you if a patient's activities of daily
living are hindered.
Example Question: What is the pain like when you stand on your foot?
Finding: Reports pain has increased in the past 2 days (Available)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 (Available)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: Reports 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: Asked location of wound
Finding: Reports 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: Reports 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: Asked details of the injury
Finding: Reports she 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 injury occurred 1 week ago (Available)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 your injury occur?