6/6/2018 Mental Health | Completed | Shadow Health
Mental Health Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-April-2018
Return to Assignment
Your Results Lab Pass
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Document: Provider Notes
Collection Objective Data
Collection Document: Provider Notes
Education & Empathy
Student Documentation Model Documentation
Documentation
Subjective cannot turn off and
Lifespan
being on the edge,
Tina Jones is a 28 year old female of African worries about the
Review Questions American descent, DOB 2/17.
HPI: came into the clinic today stating "I am here
Self-Reflection because I've been having a lot of trouble sleeping I
just feel much more nervous lately, especially right
before bed." Sleep habits are around midnight for
about an hour, unable to sleep at a resonable time,
sleep worse in general.
awakes 2 to 3 times a night for approx 10 min
each. Approx 1 mth ago onset for approx 3.5
weeks. pt reports lack of sleep effecting her daily
life, had to focus especially when trying to study
for school. racing thoughts prior to bed. Difficulty
sleeping four to five nights a week. Denies any
naps.
Reports difficulty sleeping when not able to
redirect thoughts? reports drinking caffeine to stay
alert.
Reoprts drinking up to 4 sodas per day. Denies
alcohol use or illicit drugs before bed. Reports
respiratory problems are control and not
interfering with her sleep
Denies any medicaion use for sleep but using
deep breath technique to help relax. Reports
feeling tired and out of it most of the day due to
lack of sleep and no increase in drifting off due to
lack of sleep., Reports due to lack of sleep slow
down and tired having trouble focusing generally
feeling "less sharp"
Reports feelings of anxiety as thoughts she
hhttttppss::////
wwwwww..ccoouurrsseehheerroo..ccoomm//ffiillee//4301354320418534//pMdef-n5tapld-
https://chamberlain.shadowhealth.com/assignment_attempts/3558473 1/4
, 6/6/2018 Mental Health | Completed | Shadow Health
HPI: Ms. Jones presents to the clinic complaining of di fficulty sleeping which
she notes to have started 1 month ago. She states that her sleep is “shallow
and not restful”. She complains of difficulty falling asleep at least 4 or 5 nights
per week, but states that she is able to stay asleep without di fficulty. On
average she sleeps 4 or 5 hours per night and awakens at 8:00am daily. She
states that she has a fairly consistent schedule on weekdays and weekends.
She does not take any prescription or over the counter sleep aids. She limits
screen time prior to bed and does not ingest caffeine after 4pm daily. She
endorses decreased feelings of sleepiness over the past month. She denies
difficulties awaking, but does not feel rested in the morning and has daytime
fatigue (rates 5/10 severity), restlessness, and irritability (rates 2/10 severity).
She does not take naps.
Social History: She states that she has some stress related to her upcoming
examinations and her impending job search upon graduation. She states that
she has a strong support system made up of friends and family and she is
active in her church. She states that she copes with stress by staying
organized. She enjoys reading and watching television (1-2 hours per day).
She states that her father died in a car accident a year and a half ago, which
was difficult for her and she experienced some difficulties with sleep at that
time as well. She
hhttttppss::////
wwwwww..ccoouurrsseehheerroo..ccoomm//ffiillee//4301354320418534//pMdef-n5tapld-
https://chamberlain.shadowhealth.com/assignment_attempts/3558473 2/4
Mental Health Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-April-2018
Return to Assignment
Your Results Lab Pass
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Document: Provider Notes
Collection Objective Data
Collection Document: Provider Notes
Education & Empathy
Student Documentation Model Documentation
Documentation
Subjective cannot turn off and
Lifespan
being on the edge,
Tina Jones is a 28 year old female of African worries about the
Review Questions American descent, DOB 2/17.
HPI: came into the clinic today stating "I am here
Self-Reflection because I've been having a lot of trouble sleeping I
just feel much more nervous lately, especially right
before bed." Sleep habits are around midnight for
about an hour, unable to sleep at a resonable time,
sleep worse in general.
awakes 2 to 3 times a night for approx 10 min
each. Approx 1 mth ago onset for approx 3.5
weeks. pt reports lack of sleep effecting her daily
life, had to focus especially when trying to study
for school. racing thoughts prior to bed. Difficulty
sleeping four to five nights a week. Denies any
naps.
Reports difficulty sleeping when not able to
redirect thoughts? reports drinking caffeine to stay
alert.
Reoprts drinking up to 4 sodas per day. Denies
alcohol use or illicit drugs before bed. Reports
respiratory problems are control and not
interfering with her sleep
Denies any medicaion use for sleep but using
deep breath technique to help relax. Reports
feeling tired and out of it most of the day due to
lack of sleep and no increase in drifting off due to
lack of sleep., Reports due to lack of sleep slow
down and tired having trouble focusing generally
feeling "less sharp"
Reports feelings of anxiety as thoughts she
hhttttppss::////
wwwwww..ccoouurrsseehheerroo..ccoomm//ffiillee//4301354320418534//pMdef-n5tapld-
https://chamberlain.shadowhealth.com/assignment_attempts/3558473 1/4
, 6/6/2018 Mental Health | Completed | Shadow Health
HPI: Ms. Jones presents to the clinic complaining of di fficulty sleeping which
she notes to have started 1 month ago. She states that her sleep is “shallow
and not restful”. She complains of difficulty falling asleep at least 4 or 5 nights
per week, but states that she is able to stay asleep without di fficulty. On
average she sleeps 4 or 5 hours per night and awakens at 8:00am daily. She
states that she has a fairly consistent schedule on weekdays and weekends.
She does not take any prescription or over the counter sleep aids. She limits
screen time prior to bed and does not ingest caffeine after 4pm daily. She
endorses decreased feelings of sleepiness over the past month. She denies
difficulties awaking, but does not feel rested in the morning and has daytime
fatigue (rates 5/10 severity), restlessness, and irritability (rates 2/10 severity).
She does not take naps.
Social History: She states that she has some stress related to her upcoming
examinations and her impending job search upon graduation. She states that
she has a strong support system made up of friends and family and she is
active in her church. She states that she copes with stress by staying
organized. She enjoys reading and watching television (1-2 hours per day).
She states that her father died in a car accident a year and a half ago, which
was difficult for her and she experienced some difficulties with sleep at that
time as well. She
hhttttppss::////
wwwwww..ccoouurrsseehheerroo..ccoomm//ffiillee//4301354320418534//pMdef-n5tapld-
https://chamberlain.shadowhealth.com/assignment_attempts/3558473 2/4
