Health Assess - Spring 1 2020, 322301
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Overview
Subjective Data Collection: 22 of 23 (95.7%)
Transcript
Subjective Data Collection
Hover To Reveal... Indicates an item that you
Objective Data Collection found.
Hover over the Patient Data items Indicates an item that is
Education & Empathy below to reveal important available to be found.
information, including Pro Tips and
Documentation
Example Questions.
Care Plan
Category Scored Items Patient Data
Not Scored
Experts selected these topics as essential components A combination of open and closed questions will yield
of a strong, thorough interview with this patient. better patient data. The following details are facts of t
patient's case.
Chief Complaint
Established chief complaint Reports chest pain
History of Presenting Illness
Asked about onset and duration of chest pain Reports chest pain started about five minutes ago
Reports chest pain has been constant since it
began
Reports sitting in bed when pain began
Asked to rate chest pain on a scale Reports current pain is 6/10
Asked about on characteristics of the pain Describes pain as tight and uncomfortable
Denies crushing pain
Denies gnawing or tearing pain
Denies burning pain
Asked about location of the pain Reports pain location is in middle of the chest
Reports slight pain in left shoulder
Denies arm pain
Denies back pain
Denies jaw pain
Denies neck pain
Asked about pain triggers Reports pain is aggravated by movement
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