8/28/2018 Focused Exam: PTSD | In Progress Attempt | Shadow Health
Focused Exam: PTSD (Part 3 of 4)
C487 Psych/Mental Health Clinical - Aug 2018, C487
Return to Assignment
Reflections
Activity Description: Reflective writing develops your clinical reasoning skills as you grow and improve as a clinician and gives your instructor
insight into your learning process. This reflection activity will help you think more deeply about your performance in the assignment. Use your
documentation as you respond to the prompts at the bottom of the page.
Documentation Review
Nursing Admitting...
Mental Status Note
Mental Status Note Student Response Model Documentation
SBAR
Appearance clean, well kept normal for age Ms. Diaz is a 48-year-old Cuban American
woman of average height. She appears
overweight. Eye contact is direct. Her
expression is tense and posture rigid. Her
clothing is appropriate to her age and occasion.
She appears well groomed.
Attitude cooperative, engaged, open, relaxed Ms. Diaz is cooperative, but is anxious and
appears guarded when asked about her social
history.
Motor Activity lack of eye contact, flat facial expression, no Ms. Diaz's motor activity appears agitated. She
involuntary movements has a clenched jaw and clenched fists. She has
a steady gait and continuous steps.
https://www.coursehero.com/file/38097443/Focused-Exam-PTSD-In-Progress-Attempt-Shadow-Health-mental-statuspdf/
https://wgu.shadowhealth.com/assignment_attempts/3743701 1/4
Focused Exam: PTSD (Part 3 of 4)
C487 Psych/Mental Health Clinical - Aug 2018, C487
Return to Assignment
Reflections
Activity Description: Reflective writing develops your clinical reasoning skills as you grow and improve as a clinician and gives your instructor
insight into your learning process. This reflection activity will help you think more deeply about your performance in the assignment. Use your
documentation as you respond to the prompts at the bottom of the page.
Documentation Review
Nursing Admitting...
Mental Status Note
Mental Status Note Student Response Model Documentation
SBAR
Appearance clean, well kept normal for age Ms. Diaz is a 48-year-old Cuban American
woman of average height. She appears
overweight. Eye contact is direct. Her
expression is tense and posture rigid. Her
clothing is appropriate to her age and occasion.
She appears well groomed.
Attitude cooperative, engaged, open, relaxed Ms. Diaz is cooperative, but is anxious and
appears guarded when asked about her social
history.
Motor Activity lack of eye contact, flat facial expression, no Ms. Diaz's motor activity appears agitated. She
involuntary movements has a clenched jaw and clenched fists. She has
a steady gait and continuous steps.
https://www.coursehero.com/file/38097443/Focused-Exam-PTSD-In-Progress-Attempt-Shadow-Health-mental-statuspdf/
https://wgu.shadowhealth.com/assignment_attempts/3743701 1/4
