SHADOW HEALTH: ALCOHOL
USE DISORDER, RACHEL
ADLER
[Document subtitle]
[DATE]
[COMPANY NAME]
[Company address]
, Comprehensive Emergency Department Assessment
1. Chief Complaint
1. Established reason for admission:
o "Why are you here today?"
o "What brings you in today?"
2. History of Present Illness
2. Car accident details:
o "What caused the accident?"
o "How did the accident happen?"
3. Pre-accident alcohol use:
o "How many drinks did you have?"
o "Did you drink prior to driving?"
o "Why did you choose to drink and drive?"
4. Impaired driving confirmation:
o "Were you driving impaired?"
5. Risk assessment:
o "Are you aware how dangerous drinking and driving is?"
6. Pain assessment:
o Onset/duration: "How long has the pain been going on?"
o Location: "Where is the pain located?"
o Aggravating factors: "What makes the pain worse?"
o Relieving factors: "What makes the pain better?"
o Characteristics: "Is the pain sharp or dull?"
o Severity: "On a scale of 1-10 how severe is the pain?"
3. Past Medical History
7. Health conditions:
o "Do you have any existing health conditions?"
8. Mental health:
USE DISORDER, RACHEL
ADLER
[Document subtitle]
[DATE]
[COMPANY NAME]
[Company address]
, Comprehensive Emergency Department Assessment
1. Chief Complaint
1. Established reason for admission:
o "Why are you here today?"
o "What brings you in today?"
2. History of Present Illness
2. Car accident details:
o "What caused the accident?"
o "How did the accident happen?"
3. Pre-accident alcohol use:
o "How many drinks did you have?"
o "Did you drink prior to driving?"
o "Why did you choose to drink and drive?"
4. Impaired driving confirmation:
o "Were you driving impaired?"
5. Risk assessment:
o "Are you aware how dangerous drinking and driving is?"
6. Pain assessment:
o Onset/duration: "How long has the pain been going on?"
o Location: "Where is the pain located?"
o Aggravating factors: "What makes the pain worse?"
o Relieving factors: "What makes the pain better?"
o Characteristics: "Is the pain sharp or dull?"
o Severity: "On a scale of 1-10 how severe is the pain?"
3. Past Medical History
7. Health conditions:
o "Do you have any existing health conditions?"
8. Mental health:
