SHADOW HEALTHBESTHER PARK SUBJECTIVE DATA COLLECTION: 34 OF
34 (100.0%)
Hover To Reveal...
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
• Found:
Indicates an item that you found.
• Available:
Indicates an item that is available to be found.
Category Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
Patient Data Not
Scored
A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case.
Chief Complaint
Finding:
Established chief complaint
Finding:
,Reports abdominal pain
(Found)
Pro Tip: A patient's chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient
to voice any concerns or symptoms the patient may have.
Example Question:
Do you have any abdominal pain?
Finding:
Reports difficulty with bowel movements
(Found)
Pro Tip: A patient's chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient
to voice any concerns or symptoms the patient may have.
Example Question:
Are you able to make a bowel movement?
Orientation
Finding:
Asked about orientation
Finding:
Oriented to own person
(Found)
,Pro Tip: Asking about a geriatric patient's orientation to time, place, person, and situation can help you identify whether the patient is experiencing
confusion, which can indicate underlying health issues and concerns.
Example Question:
Can you tell me your name?
Finding:
Oriented to place
(Found)
Pro Tip: Asking about a geriatric patient's orientation to time, place, person, and situation can help you identify whether the patient is experiencing
confusion, which can indicate underlying health issues and concerns.
Example Question:
Do you know where you are?
Finding:
Oriented to situation
(Found)
Pro Tip: Asking about a geriatric patient's orientation to time, place, person, and situation can help you identify whether the patient is experiencing
confusion, which can indicate underlying health issues and concerns.
Example Question:
Do you know why you are here today?
Finding:
, Oriented to time
(Found)
Pro Tip: Asking about a geriatric patient's orientation to time, place, person, and situation can help you identify whether the patient is experiencing
confusion, which can indicate underlying health issues and concerns.
Example Question:
What is today's date?
History of Presenting Illness
Finding:
Asked about onset, frequency, and duration of pain
Finding:
Reports discomfort for the past five days
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of
their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they
may be experiencing.
Example Question:
How long have you had stomach pain?
Finding:
Reports pain with gradual onset that worsened 2-3 days ago
34 (100.0%)
Hover To Reveal...
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
• Found:
Indicates an item that you found.
• Available:
Indicates an item that is available to be found.
Category Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
Patient Data Not
Scored
A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case.
Chief Complaint
Finding:
Established chief complaint
Finding:
,Reports abdominal pain
(Found)
Pro Tip: A patient's chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient
to voice any concerns or symptoms the patient may have.
Example Question:
Do you have any abdominal pain?
Finding:
Reports difficulty with bowel movements
(Found)
Pro Tip: A patient's chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient
to voice any concerns or symptoms the patient may have.
Example Question:
Are you able to make a bowel movement?
Orientation
Finding:
Asked about orientation
Finding:
Oriented to own person
(Found)
,Pro Tip: Asking about a geriatric patient's orientation to time, place, person, and situation can help you identify whether the patient is experiencing
confusion, which can indicate underlying health issues and concerns.
Example Question:
Can you tell me your name?
Finding:
Oriented to place
(Found)
Pro Tip: Asking about a geriatric patient's orientation to time, place, person, and situation can help you identify whether the patient is experiencing
confusion, which can indicate underlying health issues and concerns.
Example Question:
Do you know where you are?
Finding:
Oriented to situation
(Found)
Pro Tip: Asking about a geriatric patient's orientation to time, place, person, and situation can help you identify whether the patient is experiencing
confusion, which can indicate underlying health issues and concerns.
Example Question:
Do you know why you are here today?
Finding:
, Oriented to time
(Found)
Pro Tip: Asking about a geriatric patient's orientation to time, place, person, and situation can help you identify whether the patient is experiencing
confusion, which can indicate underlying health issues and concerns.
Example Question:
What is today's date?
History of Presenting Illness
Finding:
Asked about onset, frequency, and duration of pain
Finding:
Reports discomfort for the past five days
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of
their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they
may be experiencing.
Example Question:
How long have you had stomach pain?
Finding:
Reports pain with gradual onset that worsened 2-3 days ago
