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Tina Jones Shadow Health health history subjective data collection, neurological subjective data collection, health history SBAR, health history documentation | Spring 2025/26 - NSG 323 - Session 1 | Completed and Graded to perfection.

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Tina Jones Shadow Health health history subjective data collection, neurological subjective data collection, health history SBAR, health history documentation | Spring 2025/26 - NSG 323 - Session 1 | Completed and Graded to perfection - University of North Carolina, Wilmington.

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Health History Results | Turned In
Spring 2025 - NSG 323 - Session 1
Return to Assignment (/assignments/1087170/)




Your Results Student Results Book (/assignments/1087170/results_books/1087170?se
Lab Pass (/assignment_attempts/18271667/lab_pass.pdf)



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/

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