NR 509 ABDOMINAL PAIN
DOCUMENTATION SHADOW
HEALTH - MS. ESTHER PARK
NOTES
Orientation +1 - correct answers--Please verify your name and birthday
Chief Complaint +1 - correct answers--Do you have any pain today?
History of Presenting Illness +1 - correct answers--Can you rate your current pain level
on a scale of 0-10?
, History of Presenting Illness +1 - correct answers--Where is your pain?
History of Presenting Illness +1 - correct answers--Can you describe your pain?
History of Presenting Illness +1 - correct answers--Does anything make your pain any
better?
History of Presenting Illness +2 - correct answers--Does anything make your pain
worse?
History of Presenting Illness +1 - correct answers--Have you taken anything for your
pain?
History of Presenting Illness +1 - correct answers--When did you first notice the pain?
Social History +1 - correct answers--What was the last thing you ate?
History of Presenting Illness +1 - correct answers--Do you have difficulty going to the
bathroom?
History of Presenting Illness +2 - correct answers--How often do you go to the
bathroom?
Past Medical History +1 - correct answers--How is your diet?
Home Medications +1 - correct answers--Do you take any medications?
Home Medications +1 - correct answers--Do you take any antibiotics?
Social History +1 - correct answers--Do you eat a lot of fiber?
Review of Symptoms +1 - correct answers--How many meals a day do you eat?
Past Medical History +1 - correct answers--Have you ever had abdominal surgery?
Review of Systems +1 - correct answers--How many times do you urinate?
Social History +1 - correct answers--Do you have trouble walking?
Social History +1 - correct answers--Do you live alone?
Social History +1 - correct answers--Do you drink alcohol?
Auscultate- Abdominal Arteries - correct answers--All are no bruit
DOCUMENTATION SHADOW
HEALTH - MS. ESTHER PARK
NOTES
Orientation +1 - correct answers--Please verify your name and birthday
Chief Complaint +1 - correct answers--Do you have any pain today?
History of Presenting Illness +1 - correct answers--Can you rate your current pain level
on a scale of 0-10?
, History of Presenting Illness +1 - correct answers--Where is your pain?
History of Presenting Illness +1 - correct answers--Can you describe your pain?
History of Presenting Illness +1 - correct answers--Does anything make your pain any
better?
History of Presenting Illness +2 - correct answers--Does anything make your pain
worse?
History of Presenting Illness +1 - correct answers--Have you taken anything for your
pain?
History of Presenting Illness +1 - correct answers--When did you first notice the pain?
Social History +1 - correct answers--What was the last thing you ate?
History of Presenting Illness +1 - correct answers--Do you have difficulty going to the
bathroom?
History of Presenting Illness +2 - correct answers--How often do you go to the
bathroom?
Past Medical History +1 - correct answers--How is your diet?
Home Medications +1 - correct answers--Do you take any medications?
Home Medications +1 - correct answers--Do you take any antibiotics?
Social History +1 - correct answers--Do you eat a lot of fiber?
Review of Symptoms +1 - correct answers--How many meals a day do you eat?
Past Medical History +1 - correct answers--Have you ever had abdominal surgery?
Review of Systems +1 - correct answers--How many times do you urinate?
Social History +1 - correct answers--Do you have trouble walking?
Social History +1 - correct answers--Do you live alone?
Social History +1 - correct answers--Do you drink alcohol?
Auscultate- Abdominal Arteries - correct answers--All are no bruit
