Comprehensive Assessment
Patient: Tina Jones
Subjective Data Collection: 33 of 33
(100.0%)
Hover To Reveal...
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.
Current Health Status
Finding:
Asked about current health problems
Finding:
Denies current acute health problems
(Found)
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,10/11/23, 9:17 AM Comprehensive Assessment Tina Jones Shadow Health
Asked about current health problems
Finding:
Denies current acute health problems
(Found)
Pro Tip: Determining if the patient has any current acute health problems is essential in
conducting a productive exam and prioritzing the patient's needs.
Example Question:
Are you having any health problems?
Finding:
Reports diabetes
(Found)
Pro Tip: Confirming a patient's medical conditions, such as diabetes, will enable you to
provide the best care possible.
Example Question:
Can you confirm your diabetes?
Finding:
Reports asthma
(Found)
Pro Tip: Confirming a patient's medical conditions, such as asthma, will enable you to
provide the best care possible.
Example Question:
Can you confirm your asthma?
Finding:
Asked about last visit to a healthcare provider
Finding:
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,10/11/23, 9:17 AM Comprehensive Assessment Tina Jones Shadow Health
Finding:
Asked about last visit to a healthcare provider
Finding:
Reports last visit to a healthcare provider was 4 months ago
(Found)
Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to
develop a comprehensive health history.
Example Question:
When did you see a healthcare provider?
Finding:
Reports reason for last visit was annual gynecological exam
(Found)
Pro Tip: Establishing a timeline for Tina's gynecological exams will allow you to develop a
comprehensive health history.
Example Question:
Why did you see a healthcare provider?
Finding:
Reports last general physical examination was 5 months ago
(Available)
Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to
develop a comprehensive health history.
Example Question:
When was your last physical exam?
Finding:
Asked about current prescription medications
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, 10/11/23, 9:17 AM Comprehensive Assessment Tina Jones Shadow Health
Example Question:
When was your last physical exam?
Finding:
Asked about current prescription medications
Finding:
Reports taking diabetes medication
(Found)
Pro Tip: The medications that a patient takes indicate their health concerns or problems,
health literacy, and current treatment plans. Asking Tina if she has been taking medication for
her diabetes will indicate her treatment plan and the degree to which she is following it.
Example Question:
Have you been taking medication for your diabetes?
Finding:
Reports having an inhaler
(Found)
Pro Tip: The medications that a patient takes indicate their health concerns or problems,
health literacy, and current treatment plans. Asking Tina if she still has her inhaler will
indicate her treatment plan and the degree to which she is following it.
Example Question:
Do you have an inhaler?
Finding:
Reports taking prescription birth control pills
(Found)
Pro Tip: A patient's use of birth control can impact the care plan, such as which medications
are prescribed. Understanding a patient's history of birth control can be an indicator of health
literacy.
Example Question:
Are you taking any form of birth control?
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