Subjective Data Collection: 70 of 70 (100%)
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.
Patient Identity
Finding:
Asked about patient identity
Finding:
Reports name is Naomi
,(Found)
Pro Tip: A patient's preferred name, gender identity, and pronouns may not match the
electronic health record. Asking a patient to state how they would like to be addressed
during the interview can establish rapport and provide a comfortable and welcoming
environment.
Example Question:
What name would you like to be referred to by?
Finding:
Reports pronouns are she and her
(Available)
Pro Tip: A patient's preferred name, gender identity, and pronouns may not match the
electronic health record. Asking a patient to state how they would like to be addressed
during the interview can establish rapport and provide a comfortable and welcoming
environment.
Example Question:
, What are your pronouns?
Chief Complaint
Finding:
Asked about chief complaint
Finding:
Reports continuous fatigue
(Found)
Pro Tip: Asking your patient in open terms about the reason for their visit allows them to
explain their concerns in their own words, providing a foundation for your interview.
Example Question:
What brings you in today?
History of Present Illness
, Finding:
Asked about onset
Finding:
Reports fatigue began 2 weeks after
birth of twins
(Found)
Pro Tip: If a patient reveals a medical condition or symptoms they have, it is important to
ask a wide variety of follow-up questions about the history of the present illness. This can
help providers better understand the nature of the disorder, especially through questions
about timing, severity, and types of symptoms.
Example Question:
When did your fatigue start?
Finding:
Asked about characteristics
Finding: