Community Mental Health - Fall 2024, MTHL 9230/9246: Focused Exam: Depression Abigail Harris: 41 of 41 (100.0%)

Focused Exam: Depression Results | Turned In
Community Mental Health - Fall 2024, MTHL 9230/9246
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Overview
Subjective Data Collection: 41 of 41 (100.0%)
Transcript

Subjective Data Collection
Hover To Reveal... Indicates an item that
Objective Data Collection you found.
Hover over the Patient Data items Indicates an item that
Education & Empathy below to reveal important is available to be found.
information, including Pro Tips and
QSEN Competencies Example Questions.

Documentation

SBAR
Category Scored Items Patient Data
Reflections Not Scored

Experts selected these topics as essential A combination of open and closed questions will
components of a strong, thorough interview with yield better patient data. The following details
this patient. are facts of the patient's case.



Chief Complaint


Established chief complaint Reports feeling excessively weak
Reports fatigue and sleepiness



History of Present Illness


Asked about onset and duration of Reports symptoms have been happening
symptoms for past month
Reports symptoms have been increasing
in the past week
Reports unable to get out of bed every
morning



Asked about frequency, duration, and Reports feeling fatigued every morning
timing of symptoms Reports feeling slightly more energetic in
the afternoon



Asked about aggravating factors of Reports feeling is worse in the morning
symptoms Reports no known triggers



Asked about treatment and relieving Reports that lying down feels best when
factors of symptoms fatigued



This study source was downloaded by 100000891127392 from CourseHero.com on 10-07-2024 09:38:01 GMT -05:00
Depression Screening


https://www.coursehero.com/file/241159671/Shadow-Health-Depression-Abigail-Harris-Subjective-Data-Collectionpdf/

, Asked about pleasure and interest in typical activities Reports loss of interest in typical activities
Reports not taking pleasure in things that typically would



Asked about feelings of depression Denies sadness or depressio
Denies feeling hopeless



Asked about sleep Reports light sleep
Reports insomnia
Reports trouble falling asleep
Reports trouble staying aslee



Followed up on frequency of low energy Reports feeling low energy ne



Asked about appetite and eating Reports loss of appetite
Denies overeating



Asked about self-concept Reports feeling bad about he
Reports feeling guilty
Reports feeling embarrassed



Asked about changes in concentration Reports trouble concentrating



Asked about changes in speed with moving or speaking Denies speaking too slowly
Denies speaking too quickly
Denies moving too slowly
Denies moving too quickly



Asked about suicidal ideation and self-harm Reports "it would be ok if I did
Denies wanting to hurt hersel
Denies history of suicide attem



Past Medical History


Asked about existing health conditions Reports hypothyroidism
Reports type 2 diabetes



Followed up on history of mental health Reports depression diagnosis
Denies past psychiatric admis



Asked about allergies Denies general allergies
Denies environmental allergie
Denies latex allergy
Denies food allergies



Asked specifically about medication allergies Denies medication allergies



Home Medications


Asked about home medications Reports medications for diabe
Reports medications for depre
Reports medications for sleep
Reports medication for thyroid
Denies taking vitamins
Denies taking herbal supplem
This study source was downloaded by 100000891127392 from CourseHero.com on 10-07-2024 09:38:01 GMT -05:00

Asked about medication regimen adherence Reports using a pillbox to org
https://www.coursehero.com/file/241159671/Shadow-Health-Depression-Abigail-Harris-Subjective-Data-Collectionpdf/
Reports that her son helps he