Focused Exam: PTSD Results | Turned In
C487 Psych/Mental Health Clinical - Aug 2018, C487
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Your Results Reopen Lab Pass
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Education & Empathy : 2 of 7 (28.6%)
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Overview
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Transcript
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Subjective Data Collection During the patient interview, there are a number of opportunities to provide patient education and empathy. The
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opportunities listed below are those identified by nursing experts to be of particular importance to this patient. A
Objective Data Collection
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Model Statement is provided as an example of an appropriate response to each opportunity.
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Opportunities marked as Not Encountered are opportunities that were not elicited in the interview
Education & Empathy
Opportunities marked as Not Followed Up are missed opportunities that were present in the interview, but
where no statements were made
QSEN Competencies
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Opportunities marked as Followed Up were followed up by students, and include the dialogue between
student and patient
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Documentation
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SBAR
Overview video
1 PTSD Not Followed Up
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Reflections
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Description: Ms. Diaz describes the symptoms that she experiences as a
Student Survey result of her diagnosis of PTSD with depression.
described your mental health history (Clarified to: Can you tell me about your Question
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psychiatric history?) 04:12 PM MDT
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I was diagnosed with PTSD when I was 35. I've never been hospitalized for it.
(Clarified to: to tell you about my psychiatric history)
Question
describe your symptoms of ptsd
04:12 PM MDT
Model Statement: "PTSD is difficult for anyone who experiences it. Please
let me know if I do anything that makes you feel uncomfortable or that triggers
your symptoms. Our goal is to make your care here comfortable and a
positive experience. I can put you in touch with mental health nurses or
trauma counselors if you would like. There are also many support groups for
veterans who face the same issues, and I would be happy to refer you to
one."
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, 8/28/2018 Focused Exam: PTSD | Completed | Shadow Health
2 Patient History Not Followed Up
Description: Ms. Diaz discloses some details of the events of her MST
which led to her PTSD.
Question
how likely are you to intentionally hurt yourself
04:33 PM MDT
I don't think I'm very likely to hurt myself. I'm not actively planning anything like
that.
Question
describe your attitude (Clarified to: tell me about your stress)
04:36 PM MDT
Model Statement: "I'm sorry this happened to you. You are a survivor who
has come so far. You seem very aware of the impact that this event has had
on your life, and I commend you for directly addressing the underlying issues.
I am here if you would like to talk more about it, and if there is anything you
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need, please let me know."
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3 Suicidal Ideation Not Followed Up
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rs e Description: Ms. Diaz reports that sometimes she has suicidal thoughts,
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or feels like life is not worth living.
Question
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do you have plans of suicide
04:18 PM MDT
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I . . . I can't see myself ever planning something like that out, but sometimes I
do wonder . . . I wonder if the kind of life I'm living is worth it. I wonder if I want
to keep living like this . . . If I want to be on the edge of a cliff for the rest of my
life. I don't have faith anymore that things will get better.
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Question
have you attempted suicide?
04:20 PM MDT
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I've never attempted suicide.
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Question
medication regime adherence
04:20 PM MDT
I use an app on my smartphone to manage my medications. I get alerts when
I need to take them.
Model Statement: "When you say that life is not worth living, you are
talking about suicide. I understand that you are facing a difficult time with your
sleep issues and your history, but we can focus on how to move forward and
get you help. I would recommend counseling. I would like to refer you to
counseling, and resources like a national suicide prevention hotline."
4 Smoking Cessation Not Followed Up
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