Subjective Data Collection Chief Complaint -establish chief complaint -reports feeling excessively weak -Do you feel weak? -reports fatigue and sleepiness -Are you fatigued?
History of Present Illness -asked about onset and duration of symptoms -reports symptoms have been happening for past month -How often have you felt fatigue? -reports symptoms have been increasing in the past week -Did the discomfort start gradually? -reports unable to get out of bed every morning -Can you get out of bed? -asked about frequency, duration, and timing of symptoms -reports feeling fatigued every morning -Are you tired in the morning? -reports feeling slightly more energetic in the afternoon -Are you tired in the afternoon? -asked about aggravating factors of symptoms -reports feeling is worse in the morning -When do the symptoms feel worse? -reports no known triggers -What makes your symptoms worse? -asked about treatment and relieving factors of symptoms -reports that lying down feels best when fatigued -What relieves your symptoms?
Depression Screening -asked about pleasure and interest in typical activities -reports loss of interest in typical activities -Do you have little interest in doing things? -reports not taking pleasure in things that typically would -Do you not find pleasure in things you used to like? -asked about feeling of depression -denies sadness or depression -Do you feel sad or depressed? -denies feeling hopeless -Do you ever feel hopeless? -asked about sleep -reports light sleep -How much sleep do you get at night? -reports insomnia -Have you ever had insomnia? -reports trouble falling asleep -Do you have trouble falling asleep? -reports trouble staying asleep -Do you have trouble staying asleep? -followed up on frequency of low energy -reports feeling low energy nearly every day -How often have you felt you had low energy? -asked about appetite and eating -reports loss of appetite -Have you ever lost your appetite? -denies overeating -Do you overeat? -asked about self-concept -reports feeling bad about herself -Do you feel bad about your-self? -reports feeling guilty -Do you ever feel guilty? -reports feeling embarrassed -Have you been feeling embarrassed? -asked about changes in concentration -reports trouble concentrating -Have you been having trouble concentrating? -asked about changes in speed with moving of speaking -denies speaking too slowly -denies speaking too quickly -denies moving too slowly -denies moving too quickly -asked about suicidal ideation and self-harm -reports “it would be ok if I didn’t wake up” -How often have you felt like you would rather be dead? -denies wanting to hurt herself -Have you ever thought about hurting yourself? -denies history of suicide attempts -Have you ever attempted suicide?
Past Medical History -asked about existing health conditions -reports hypothyroidism -Are you aware of any thyroid problems? -reports type 2 diabetes -Do you diabetes? -followed up on history of mental health -reports depression diagnosis -Have you ever experienced depression? -denies past psychiatric admissions -Have you had to go to the hospital for a psychiatric disorder? -asked about allergies -denies general allergies -denies environmental allergies -denies latex allergy -denies food allergies -asked specifically about medication allergies -denies medication allergies Home Medications -asked about home medications -reports medications for diabetes -reports medications for depression -reports medications for sleep -reports medications for thyroid
History of Present Illness -asked about onset and duration of symptoms -reports symptoms have been happening for past month -How often have you felt fatigue? -reports symptoms have been increasing in the past week -Did the discomfort start gradually? -reports unable to get out of bed every morning -Can you get out of bed? -asked about frequency, duration, and timing of symptoms -reports feeling fatigued every morning -Are you tired in the morning? -reports feeling slightly more energetic in the afternoon -Are you tired in the afternoon? -asked about aggravating factors of symptoms -reports feeling is worse in the morning -When do the symptoms feel worse? -reports no known triggers -What makes your symptoms worse? -asked about treatment and relieving factors of symptoms -reports that lying down feels best when fatigued -What relieves your symptoms?
Depression Screening -asked about pleasure and interest in typical activities -reports loss of interest in typical activities -Do you have little interest in doing things? -reports not taking pleasure in things that typically would -Do you not find pleasure in things you used to like? -asked about feeling of depression -denies sadness or depression -Do you feel sad or depressed? -denies feeling hopeless -Do you ever feel hopeless? -asked about sleep -reports light sleep -How much sleep do you get at night? -reports insomnia -Have you ever had insomnia? -reports trouble falling asleep -Do you have trouble falling asleep? -reports trouble staying asleep -Do you have trouble staying asleep? -followed up on frequency of low energy -reports feeling low energy nearly every day -How often have you felt you had low energy? -asked about appetite and eating -reports loss of appetite -Have you ever lost your appetite? -denies overeating -Do you overeat? -asked about self-concept -reports feeling bad about herself -Do you feel bad about your-self? -reports feeling guilty -Do you ever feel guilty? -reports feeling embarrassed -Have you been feeling embarrassed? -asked about changes in concentration -reports trouble concentrating -Have you been having trouble concentrating? -asked about changes in speed with moving of speaking -denies speaking too slowly -denies speaking too quickly -denies moving too slowly -denies moving too quickly -asked about suicidal ideation and self-harm -reports “it would be ok if I didn’t wake up” -How often have you felt like you would rather be dead? -denies wanting to hurt herself -Have you ever thought about hurting yourself? -denies history of suicide attempts -Have you ever attempted suicide?
Past Medical History -asked about existing health conditions -reports hypothyroidism -Are you aware of any thyroid problems? -reports type 2 diabetes -Do you diabetes? -followed up on history of mental health -reports depression diagnosis -Have you ever experienced depression? -denies past psychiatric admissions -Have you had to go to the hospital for a psychiatric disorder? -asked about allergies -denies general allergies -denies environmental allergies -denies latex allergy -denies food allergies -asked specifically about medication allergies -denies medication allergies Home Medications -asked about home medications -reports medications for diabetes -reports medications for depression -reports medications for sleep -reports medications for thyroid
