Spring 2025 - NSG 323 - Session 1
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Overview
Subjective Data Collection: 63 of 64 (98.4%)
Transcript
Subjective Data Collection
Hover To Reveal... Indicates an item that
Education & Empathy you found.
Hover over the Patient Data Indicates an item that
Documentation items below to reveal important is available to be found.
information, including Pro Tips
Interpret Findings
and Example Questions.
SBAR
Video Tutorial
Catego Scored Items Patient Data
Health History Tips and Tricks
Not Scored
Reflection Questions
ry
Experts selected these topics as essential A combination of open and closed questions
components of a strong, thorough interview with will yield better patient data. The following
this patient. details are facts of the patient's case.
Chief Complaint
Established chief complaint Reports pain from wound on right foot
History of Present Illness
Asked about onset of injury Reports scraped foot on bottom rung of a
step stool 1 week ago
Reports being barefoot at time of injury
Asked about wound location Reports injury on plantar surface of right
foot
Asked about duration of pain Reports pain is constant
This study source was downloaded by 100000900703063 from CourseHero.com on 02-05-2026 00:07:10 GMT -06:00
Asked about characteristics of pain Reports pain is throbbing
https://www.coursehero.com/file/247287812/Shadow-Health-health-history-subjective-data-collectionpdf/
, Reports pain is sharp when attempting to stand
Reports pain is radiating into ankle
Asked about associated factors Reports swelling around foo
Reports swelling worsened
Reports redness around the
Reports that the wound fee
Reports wound draining pus
Followed up on drainage Reports pus is white or yello
Denies odor from the wound
Asked about aggravating factors Reports standing or bearing
foot
Asked about relieving factors Reports pain medication les
Followed up on pain medication Reports taking 2 pills of reg
times a day, for the past 2 da
Reports pain returned in ful
Asked about home treatment of foot wound Reports bandaging the wou
Reports cleaning the wound
Reports applying bacitracin
ointment
Asked about severity of pain Reports pain is a 7 out of 10
Reports pain has increased
Past Medical History
Asked about preexisting medical conditions Reports diabetes
Reports asthma
Followed up on diabetes diagnosis Reports diabetes diagnosis
Reports type 2 diabetes
Asked about diabetes management Reports reducing sugar inta
Asked about blood glucose monitoring Reports infrequent blood gl
Reports last checked blood
Reports being confused abo
Followed up on asthma diagnosis Reports asthma diagnosis a
Asked about prior hospitalizations Reports last hospitalization
Reports about 5 total hospit
child and teen
This study source was downloaded by 100000900703063 from CourseHero.com on 02-05-2026 00:07:10 GMT -06:00
https://www.coursehero.com/file/247287812/Shadow-Health-health-history-subjective-data-collectionpdf/
, Asked about allergies Denies latex allergy
Denies food allergies
Reports penicillin allergy
Followed up on penicillin allergy Reports penicillin resulted in
Reports last penicillin reacti
Asked about environmental allergies Reports allergy to cats
Reports cats cause sneezin
Reports dust causes sneez
Asked about vitamins and supplements Denies taking vitamins or su
Asked about general immunizations Reports being up to date on
Asked about influenza vaccination Denies receiving annual flu
Asked about tetanus immunization Reports last tetanus vaccina
Asked about COVID vaccinations Reports being up to date on
Asked about use of OTC medications Reports occasionally taking
Reports occasionally taking
headaches
Asked about current diabetes medication Denies taking diabetes med
Asked about past diabetes medication Reports stopping metformin
Reports metformin had adv
Reports not liking checking
taking daily pills
Asked about asthma management Reports using albuterol inha
Reports last asthma attack
Reports last exacerbation a
ago
Reports using inhaler no mo
Reports typically taking 2 pu
sometimes needs 3 puffs
Asked about asthma triggers Reports asthma triggered b
Social History
Asked about stressors Reports stress over foot inju
Asked about living situation Reports living at home with
This study source was downloaded by 100000900703063 from CourseHero.com on 02-05-2026 00:07:10 GMT -06:00
Reports family members wi
activities
https://www.coursehero.com/file/247287812/Shadow-Health-health-history-subjective-data-collectionpdf/