HEALTH
HEALTH
HISTORY
SUBJECTIVE
Subjective Data Collection: 88 of 88
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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 being worn at the time of injury helps you discover the totality of the
circumstances.Example Question:Were you wearing shoes when you fell?
Finding: Has not seen a healthcare provider for the injury (Found)Pro Tip: It's crucial to ask whether
your patient has seen another provider for the injury, because any previous medical intervention will
help you