Shadow Health - Tina Jones, Health History
Subjective Data Collection - Checklist:
Chief Complaint
Finding: Established chief complaint
Example Question: Do you have any pain?
Finding: Reports 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: What's causing your pain?
Finding: Reports foot wound (Found)Pro Tip: If a patient
mentions pain, it's important to determine what specifically is
causing her pain, if she knows.
History of Presenting Illness
Finding: Asked to rate current pain level on a scale
Example Question: Can you rate the pain on a scale of 0 to 10?
Finding: Reports current pain is 7/10 (Found)Pro Tip: Asking
your patient to rate her pain on a scale of 0 to 10 is important to
gauge how it ebbs and flows while she is in your care.
Finding: Asked for details about the pain
Example Question: Can you please describe the pain?
,Finding: Reports pain is throbbing (Found)Pro Tip: Determining
how your patient describes the characteristics of the pain can be
important data to support the cause of the pain.
Example Question: What is the pain like when you stand on
your foot?
Finding: Reports pain is sharp when she attempts to stand
(Found)Pro Tip: Determining what physical activities and
movements exacerbate the patient's pain can help you better
understand the problems and assess treatment needs. This can
also alert you if a patient's activities of daily living are hindered.
Example Question: How has the pain changed over time?
Finding: Reports pain has increased in the past 2 days
(Available)Pro Tip:Finding out how the patient's pain has
changed will give you insight into the acceleration of infection.
Example Question: Does the pain radiate anywhere else?
Finding: Reports feeling pain radiating into ankle (Available)Pro
Tip: Asking about where else the patient's pain radiates can help
determine the progression of infection.
Example Question: Can you bear weight on your foot?
Finding: Reports pain prevents bearing weight on foot
(Found)Pro Tip: Determining if your patient can bear weight on
an injury is important to determine their risk for falls while in
your care.
Finding: Asked location of wound
Example Question: Which foot is in pain?
,Finding: Reports right foot is injured (Found)Pro Tip:
Confirming which extremity an injury is located is a best
practice for your patient's safety.
Example Question: Where is the wound?
Finding: Reports wound is on the plantar surface of her foot
(Found)Pro Tip: Confirming where a wound is located ensures
you are aware of your patient's biggest complaint.
Finding: Asked details of the injury
Example Question: How did your injury happen?
Finding: Reports she scraped foot on bottom rung of a step stool
(Found)Pro Tip: Discovering how an injury happened helps to
assess your patient's risk factors for injury.
Example Question: When did your injury occur?
Finding: Reports injury occurred 1 week ago (Available)Pro
Tip: Discovering how long ago the pain began is the first step in
understanding whether the pain is chronic or acute.
Example Question: Did you injure anything besides your foot?
Finding: Denies other injuries besides foot wound
(Available)Pro Tip: Discovering additional injuries can reveal
more information about the circumstances that caused the
presenting injury.
Example Question: Were you wearing shoes when you fell?
Finding: Reports being barefoot at the time of injury
(Available)Pro Tip: Asking about clothing, footwear, and other
, protective elements being worn at the time of injury helps you
discover the totality of the circumstances.
Example Question: Have you seen a healthcare provider for this
injury?
Finding: Denies seeing a healthcare provider for the injury until
now (Available)Pro Tip: It's crucial to ask whether your patient
has seen another provider for the injury, because any previous
medical intervention will help you understand the progression of
the wound.
Finding: Asked about drainage from the foot wound
Example Question: Did your foot bleed?
Finding: Reports that the wound bled a little after sustaining the
injury (Available)Pro Tip: Asking about bleeding helps you
determine the characteristics of a wound.
Example Question: Did you notice any discharge from the
wound?
Finding: Reports seeing pus draining from wound (Found)Pro
Tip: Asking about discharge helps you determine the
characteristics of a wound.
Example Question: When did you first notice the pus?
Finding: Reports noticing pus 2 days ago (Available)Pro Tip:
Pinpointing exactly when the patient noticed the arrival of pus
gives you an important data point for when an active infection
began.
Finding: Followed up on drainage
Subjective Data Collection - Checklist:
Chief Complaint
Finding: Established chief complaint
Example Question: Do you have any pain?
Finding: Reports 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: What's causing your pain?
Finding: Reports foot wound (Found)Pro Tip: If a patient
mentions pain, it's important to determine what specifically is
causing her pain, if she knows.
History of Presenting Illness
Finding: Asked to rate current pain level on a scale
Example Question: Can you rate the pain on a scale of 0 to 10?
Finding: Reports current pain is 7/10 (Found)Pro Tip: Asking
your patient to rate her pain on a scale of 0 to 10 is important to
gauge how it ebbs and flows while she is in your care.
Finding: Asked for details about the pain
Example Question: Can you please describe the pain?
,Finding: Reports pain is throbbing (Found)Pro Tip: Determining
how your patient describes the characteristics of the pain can be
important data to support the cause of the pain.
Example Question: What is the pain like when you stand on
your foot?
Finding: Reports pain is sharp when she attempts to stand
(Found)Pro Tip: Determining what physical activities and
movements exacerbate the patient's pain can help you better
understand the problems and assess treatment needs. This can
also alert you if a patient's activities of daily living are hindered.
Example Question: How has the pain changed over time?
Finding: Reports pain has increased in the past 2 days
(Available)Pro Tip:Finding out how the patient's pain has
changed will give you insight into the acceleration of infection.
Example Question: Does the pain radiate anywhere else?
Finding: Reports feeling pain radiating into ankle (Available)Pro
Tip: Asking about where else the patient's pain radiates can help
determine the progression of infection.
Example Question: Can you bear weight on your foot?
Finding: Reports pain prevents bearing weight on foot
(Found)Pro Tip: Determining if your patient can bear weight on
an injury is important to determine their risk for falls while in
your care.
Finding: Asked location of wound
Example Question: Which foot is in pain?
,Finding: Reports right foot is injured (Found)Pro Tip:
Confirming which extremity an injury is located is a best
practice for your patient's safety.
Example Question: Where is the wound?
Finding: Reports wound is on the plantar surface of her foot
(Found)Pro Tip: Confirming where a wound is located ensures
you are aware of your patient's biggest complaint.
Finding: Asked details of the injury
Example Question: How did your injury happen?
Finding: Reports she scraped foot on bottom rung of a step stool
(Found)Pro Tip: Discovering how an injury happened helps to
assess your patient's risk factors for injury.
Example Question: When did your injury occur?
Finding: Reports injury occurred 1 week ago (Available)Pro
Tip: Discovering how long ago the pain began is the first step in
understanding whether the pain is chronic or acute.
Example Question: Did you injure anything besides your foot?
Finding: Denies other injuries besides foot wound
(Available)Pro Tip: Discovering additional injuries can reveal
more information about the circumstances that caused the
presenting injury.
Example Question: Were you wearing shoes when you fell?
Finding: Reports being barefoot at the time of injury
(Available)Pro Tip: Asking about clothing, footwear, and other
, protective elements being worn at the time of injury helps you
discover the totality of the circumstances.
Example Question: Have you seen a healthcare provider for this
injury?
Finding: Denies seeing a healthcare provider for the injury until
now (Available)Pro Tip: It's crucial to ask whether your patient
has seen another provider for the injury, because any previous
medical intervention will help you understand the progression of
the wound.
Finding: Asked about drainage from the foot wound
Example Question: Did your foot bleed?
Finding: Reports that the wound bled a little after sustaining the
injury (Available)Pro Tip: Asking about bleeding helps you
determine the characteristics of a wound.
Example Question: Did you notice any discharge from the
wound?
Finding: Reports seeing pus draining from wound (Found)Pro
Tip: Asking about discharge helps you determine the
characteristics of a wound.
Example Question: When did you first notice the pus?
Finding: Reports noticing pus 2 days ago (Available)Pro Tip:
Pinpointing exactly when the patient noticed the arrival of pus
gives you an important data point for when an active infection
began.
Finding: Followed up on drainage
