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Shadow Health -Nicole Diaz- PTSD Complete Solution Guide..

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FOCUSED EXAM_ PTSD
_ COMPLETED _
SHADOW HEALTH
DOCUMENTATION.PDF




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8/28/2018 Focused Exam: PTSD | Completed | Shadow Health



Focused Exam: PTSD Results | Turned In
C487 Psych/Mental Health Clinical - Aug 2018, C487
Return to Assignment




Your Results Reopen Lab Pass



Overview
Documentation / Electronic Health Record




m
er as
Transcript




co
Subjective Data Collection Flowsheets Documentation




eH w
Objective Data Collection




o.
Education & Empathy
rs e
Nursing Admitting Note
ou urc
QSEN Competencies
Student Documentation Model Documentation
Documentation
o
aC s

Chief Complaint Ms. Diaz presented at the clinic with severe sleep
SBAR
issues that she said were impacting her life. She
vi y re


not being able to sleep, trouble following asleep claimed she was unable to rest and was suffering
Overview video from insomnia, nightmares, and frequent waking.

Reflections
ed d




Student Survey History of Present Illness
ar stu




Nicole is a 48 year-old Cuban American woman with
cant sleep until 2 or 3 in the morning, too nervous to
a history of hypertension and post-traumatic stress
sleep, only getting four or five hours of sleep per
disorder.
night, history of PTSD
is




Allergies
Th




NKA
nkda
sh




Past Medical History HTN diagnosed age 45
PTSD diagnosed age 35 stemming from a sexual
htn, ptsd
assault during her military service




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