SHADOW HEALTH HEALTH HISTORY SUBJECTIVE
subjectiveSubjective Data Collection: 88 of 88 (100.0%)
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.
•
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?
•
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
(Available)
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
(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:
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)
subjectiveSubjective Data Collection: 88 of 88 (100.0%)
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.
•
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?
•
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
(Available)
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
(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:
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)
