Complete Shadow Health Depression Abigail_Harris Documentation Electronic Health_Record.
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Course
MTHL 9230/9246 (MTLH9230)
Institution
Niagara College (
)
Focused Exam: Depression Results | Turned In
Community Mental Health - Fall 2024, MTHL 9230/9246
Shadow Health Depression Abigail Harris Documentation Electronic Health Record
Focused Exam: Depression Results | Turned In
Community Mental Health - Fall 2024, MTHL 9230/9246
Return to Assignment (/assignments/1023526/)
Your Results Lab Pass (/assignment_attempts/17525311/lab_pass.pdf)
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Flowsheets Documentation
Objective Data Collection
Nursing Admitting Note
Education & Empathy
QSEN Competencies Student Documentation Model Documentation
Documentation Chief Complaint
SBAR Ms. Abigail Harris is an 86-year-old African American
Patient complaints of feeling excessive fatigue and woman who presented in the ED with weakness and
weakness. Patient also complains of being constantly tired fatigue.
Reflections and sleepy.
Reports weakness and fatigue for last month, increasing
History of Present Illness over last 7 days. Ms. Harris is occasionally unable to get
out of bed in the morning. The timing of fatigue is every
Patient stated that she has been feeling fatigued every morning. Reports that her fatigue is somewhat alleviated by
morning and weak for the last month and has been unable lying down, and that she has slightly more energy in the
to get out of bed especially increasing on the past 7 days. afternoon. No known triggers.
She stated that she feels better when lying down and and
is more energetic in the afternoon. According to her, she Reports feeling guilty about appearance and lack of social
doesn't like what she looks, and feeling guilty for not being interaction last two weeks. Reports not leaving her house
able to leave the house and socialize for the last 2 weeks. much. She reports a depression diagnosis, and her current
She said that she has been diagnosed with depression. depression screening shows her positive for moderate
depressive symptoms.
Allergies
Patient denies any allergies to food medication and NKA
environment.
Past Medical History
Hypothyroidism age 50
DM Type II age 50
Patient reports she has been diagnosed with Depression age 81
hypothyroidism and diabetes at the age of 50. Patient
reports diagnosis of depression at the age of 81. She has Previous hospitalization (36 years ago) for fatigue and
been hospitalized 36 years ago for fatigue and weight loss. weight loss related to DM II and hypothyroidism
Past Surgical History
No previous surgeries.
No surgical history
Medication History
Insulin aspart 16 units SC three times a day with meals. Insulin aspart: 16 units, SC, TID mealtimes
Angeline glargine 45 units subcutaneous once daily. Insulin glargine: 45 units, SC, daily
Level thyroxine 50 micrograms per oral once daily. Levothyroxine: 50 mcg, P.O., daily
Venlafaxine extended release (Effexor XR) 150 mg per oral Venlafaxine extended-release (Effexor XR): 150 mg P.O.
once daily. daily
This study source was downloaded by 100000891127392
Zolpidem 5 mg perfrom CourseHero.com
oral bedtime for10:14:32Zolpidem:
on 10-07-2024
as necessary during 5 mg, P.O., PRN at bedtime
GMT -05:00
sleep issues
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