- Advanced Health Assessment - August 2023,
D028
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Overview
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Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Subjective Data Collection: 31 of 31
(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.
Chief Complaint
Finding:
Established chief complaint
Finding:
Reports frequently occurring stomach 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:
How are you feeling?
History of Present Illness
Finding:
Asked about onset of pain
,
Finding:
Reports noticing pain for "at least a month"
(Found)
Pro Tip: By establishing a timeline of Tina's abdominal pain, you're soliciting
information that can help you to understand the nature and extent of her stomach
pain.
Example Question:
How long have you had abdominal pain?
Finding:
Reports that pain increased gradually
(Found)
Pro Tip: By establishing a timeline of Tina's abdominal pain, you're soliciting
information that can help you to understand the nature and extent of her stomach
pain.
Example Question:
Did the abdominal pain start suddenly?
Finding:
Asked about frequency of pain
Finding:
Reports pain occurs every day
, (Found)
Pro Tip: By establishing a timeline of Tina's abdominal pain, you're soliciting
information that can help you to understand the nature and extent of her stomach
pain.
Example Question:
Do you have abdominal pain every day?
Finding:
Reports 3 to 4 episodes a week that are more severe
(Available)
Pro Tip: By establishing a timeline of Tina's abdominal pain, you're soliciting
information that can help you to understand the nature and extent of her stomach
pain.
Example Question:
How many times a week do you have abdominal pain?
Finding:
Asked about duration of pain
Finding:
Pain begins right after finishing a meal
(Available)
Pro Tip: Soliciting information about what triggers Tina's stomach pain can allow
you to understand the nature of her symptoms and most effectively treat her.