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Advanced Nursing Practice I - Primary Care - Adult
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Overview
Subjective Data Collection: 75 of 75 (100.0%)
Transcript
Subjective Data Collection
Hover To Reveal... Indicates an item that
Objective Data Collection you found.
Hover over the Patient Data items Indicates an item that
Education & Empathy below to reveal important
is available to be found.
information, including Pro Tips and
Documentation Example Questions.
Treatment Plan
Reflection
Category Scored Items Patient Data
Not Scored
Experts selected these topics as essential A combination of open and closed questions
components of a strong, thorough interview will yield better patient data. The following
with this patient. details are facts of the patient's case.
Telehealth Protocol
Asked patient if they are in an Confirms they are at a space where the
appropriate environment for a visit visit can be conducted
Asked if they can hear provider Confirms they are able to hear provider
Inform the patient this is a confidential Acknowledges that they are aware that
protected visit this is a confidential protected visit
Episodic Heart Failure Questionnaire
Asked how patient is doing Reports doing well
, Asked about taking vital signs Reports taking vitals daily
Reports taking vitals at the same time each day
Reports no problems with equipment
Asked about respiratory symptoms Denies cough
Denies wheezing
Denies shortness of breath o
Denies any trouble breathing
Asked about cardiovascular symptoms Denies chest pain
Denies palpitations
Reports swelling
Asked about location of swelling Reports swelling in feet and
Asked about onset of swelling Reports noticing swelling wit
Asked about character of swelling Reports feet and ankles are
Reports socks left indentatio
Asked about integumentary symptoms Denies itchy, dry skin
Asked about taking daily weight logs Reports taking daily weight l
Reports weighing self at the
Reports wearing same type
everyday
Asked about changes to weight Reports weight gain
Reports gaining 4-5 lbs
Asked about timing of weight gain Reports noticing weight gain
Asked about pain status Denies pain
Asked about typical diet Reports limiting sodium intak
Reports typical breakfast as
Reports typical lunch as sala
pasta with grilled chicken and
Reports typical dinner as gril
roasted vegetables, brown rice
Reports typical snack as no-
apple, no-salt air popped pop
Followed up on any recent changes to typical diet Reports straying from typical
Reports eating large amount