8/28/2018 Focused Exam: Depression | In Progress Attempt | Shadow Health
Focused Exam: Depression (Part 3 of 3)
C487 Psych/Mental Health Clinical - Aug 2018, C487
Return to Assignment
Reflections
m
er as
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
co
documentation as you respond to the prompts at the bottom of the page.
eH w
o.
Documentation Review
rs e
ou urc
Nursing Admitting...
Nursing Admitting Note
Mental Status Note Student Response Model Documentation
o
SBAR
aC s
vi y re
Chief Complaint exhaustion/weakness Ms. Abigail Harris is an 86-year-old African
American woman who presented in the ED with
weakness and fatigue.
ed d
ar stu
History of onset was one month PTA, progressively Reports weakness and fatigue for last month,
Present Illness becoming worse, worse in the morning increasing over last 7 days. Ms. Harris is
occasionally unable to get out of bed in the
sh is
morning. The timing of fatigue is every morning.
Reports that her fatigue is somewhat alleviated
Th
by lying down, and that she has slightly more
energy in the afternoon. No known triggers.
Reports feeling guilty about appearance and
lack of social interaction last two weeks.
Reports not leaving her house much. She
reports a depression diagnosis, and her current
depression screening shows her positive for
moderate depressive symptoms.
Allergies (No Documentation Made) NKA
https://www.coursehero.com/file/38097444/Focused-Exam-Depression-In-Progress-Attempt-Shadow-Healthpdf/
https://wgu.shadowhealth.com/assignment_attempts/3742618 1/5
, 8/28/2018 Focused Exam: Depression | In Progress Attempt | Shadow Health
Student Response Model Documentation
Past Medical type 2 diabetes, depression, underactive thyroid Hypothyroidism age 50
History DM Type II age 50
Depression age 81
Previous hospitalization (36 years ago) for
fatigue and weight loss related to DM II and
hypothyroidism
Past Surgical none No previous surgeries.
History
m
er as
Medication insulin two different types, effexor Insulin aspart: 16 units, SC, TID mealtimes
History Insulin glargine: 45 units, SC, daily
co
Levothyroxine: 50 mcg, P.O., daily
eH w
Venlafaxine extended-release (Effexor XR): 150
mg P.O. daily
o.
Zolpidem: 5 mg, P.O., PRN at bedtime
rs e
ou urc
o
Family History father heart disease and HTN, mother arthritis No family history of mental illness.
aC s
vi y re
Social History drinkins occasionaly with dinner, one drink Occupations: Retired high school English
ed d
no smoking teacher.
denied drug use
ar stu
Marital Status: Widowed; husband died six
years ago.
Substance Use: Never used tobacco. Drinks
sh is
one alcoholic beverage less than once a month.
Th
Religion: Christian (Non-denominational).
Her son is her primary caregiver and helps her
manage medications, including refilling and
picking up prescriptions and ensuring she is
complaint. Ms. Harris reports that her
depression started after the loss of her
husband. Since then, she has moved in with
her son and his family. Previously had
organized a knitting group at her church and
attended weekly, and walked most evenings for
her dog and for exercise and stress
management.
https://www.coursehero.com/file/38097444/Focused-Exam-Depression-In-Progress-Attempt-Shadow-Healthpdf/
https://wgu.shadowhealth.com/assignment_attempts/3742618 2/5
Focused Exam: Depression (Part 3 of 3)
C487 Psych/Mental Health Clinical - Aug 2018, C487
Return to Assignment
Reflections
m
er as
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
co
documentation as you respond to the prompts at the bottom of the page.
eH w
o.
Documentation Review
rs e
ou urc
Nursing Admitting...
Nursing Admitting Note
Mental Status Note Student Response Model Documentation
o
SBAR
aC s
vi y re
Chief Complaint exhaustion/weakness Ms. Abigail Harris is an 86-year-old African
American woman who presented in the ED with
weakness and fatigue.
ed d
ar stu
History of onset was one month PTA, progressively Reports weakness and fatigue for last month,
Present Illness becoming worse, worse in the morning increasing over last 7 days. Ms. Harris is
occasionally unable to get out of bed in the
sh is
morning. The timing of fatigue is every morning.
Reports that her fatigue is somewhat alleviated
Th
by lying down, and that she has slightly more
energy in the afternoon. No known triggers.
Reports feeling guilty about appearance and
lack of social interaction last two weeks.
Reports not leaving her house much. She
reports a depression diagnosis, and her current
depression screening shows her positive for
moderate depressive symptoms.
Allergies (No Documentation Made) NKA
https://www.coursehero.com/file/38097444/Focused-Exam-Depression-In-Progress-Attempt-Shadow-Healthpdf/
https://wgu.shadowhealth.com/assignment_attempts/3742618 1/5
, 8/28/2018 Focused Exam: Depression | In Progress Attempt | Shadow Health
Student Response Model Documentation
Past Medical type 2 diabetes, depression, underactive thyroid Hypothyroidism age 50
History DM Type II age 50
Depression age 81
Previous hospitalization (36 years ago) for
fatigue and weight loss related to DM II and
hypothyroidism
Past Surgical none No previous surgeries.
History
m
er as
Medication insulin two different types, effexor Insulin aspart: 16 units, SC, TID mealtimes
History Insulin glargine: 45 units, SC, daily
co
Levothyroxine: 50 mcg, P.O., daily
eH w
Venlafaxine extended-release (Effexor XR): 150
mg P.O. daily
o.
Zolpidem: 5 mg, P.O., PRN at bedtime
rs e
ou urc
o
Family History father heart disease and HTN, mother arthritis No family history of mental illness.
aC s
vi y re
Social History drinkins occasionaly with dinner, one drink Occupations: Retired high school English
ed d
no smoking teacher.
denied drug use
ar stu
Marital Status: Widowed; husband died six
years ago.
Substance Use: Never used tobacco. Drinks
sh is
one alcoholic beverage less than once a month.
Th
Religion: Christian (Non-denominational).
Her son is her primary caregiver and helps her
manage medications, including refilling and
picking up prescriptions and ensuring she is
complaint. Ms. Harris reports that her
depression started after the loss of her
husband. Since then, she has moved in with
her son and his family. Previously had
organized a knitting group at her church and
attended weekly, and walked most evenings for
her dog and for exercise and stress
management.
https://www.coursehero.com/file/38097444/Focused-Exam-Depression-In-Progress-Attempt-Shadow-Healthpdf/
https://wgu.shadowhealth.com/assignment_attempts/3742618 2/5
