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Focused Exam Schizophrenia Completed Shadow Health Eric Ford Transcript
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10/16/24, 11:52 Focused Exam Schizophrenia Completed Shadow Health Eric FordAM Trans…
7/24/2021 Focused Exam: Schizophrenia | Completed | Shadow Health
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Focused Exam: Schizophrenia Results |
Completed
ICHS - Capstone Spring 2021 - June 2021, nur2811ug
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Overview
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t
Subjective Data Started: Jul 21, 2021 | Total Time: 792 min
Collection Objective All Lines Interview Questions (177) Statements (17) Exam Actions (35)
(229)
Data Collection
Education & Gr
Hello, I'm Precious and I'll be taking care of you today
07/21/21 8:23 PM E
Empathy QSEN
Competencies Hey there.
Documentation
Great job! This question is open-ended enough to allow the patient to respond
Care Plan
flexibly about the symptoms bothering them and their reason for being in the
hospital.
Reflectio
Questi
ns 07/21/21 8:27 PM E
What brings you to the hospital today?
Look. I'm not crazy, OK. I've got some problems, I know, but I'm not crazy. It's
these voices I get. They're everywhere and everyone and they just kept getting
louder. They kept getting harsher... just awful.
Great job! This question seeks further clarification about what the patient has
said without outright rejecting or validating what they are experiencing.
Questi
07/21/21 8:29 PM E
Can I ask who is telling you that your life is almost over?
I mean these voices I keep hearing, they keep telling me my life is almost over
and I can't get them to stop. Do you hear them?
Great job! This empathetic response acknowledges the potentially frightening
nature of auditory hallucinations and presents reality in way that does not
diminish the patient's experience.
Support
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,10/16/24, 11:52 Focused Exam Schizophrenia Completed Shadow Health Eric Ford
AM Trans…
7/24/2021 Focused Exam: Schizophrenia | Completed | Shadow Health
I don't hear anything. That sounds frightening, but please know you are safe here Questi
in the hospital. 07/21/21 8:31 PM E
Thanks. I know I have had issues in the past with hallucinations, but sometimes
they feel so real.
Great job! This educational response casts doubt on the patient's delusion, and
gives reassurance about the safety, and information about the therapeutic
effects of his medication.
Questi
I don't see any evidence of that. Taking your medication may lower the frequency 07/21/21 8:33 PM E
of voices you hear.
I guess that's true. Not everything these voices tell me is true and maybe the
medication would help get rid of them.
Questi
What brings you in today? 07/21/21 9:02 PM E
Look. I'm not crazy, OK. I've got some problems, I know, but I'm not crazy. It's
these voices I get. They're everywhere and everyone and they just kept getting
louder. They kept getting harsher... just awful.
Questi
Do you ever hear things that others do not hear? 07/21/21 9:03 PM E
Yeah, it's bad. I hear voices, people I don't know talking to me from inside my head.
I can hear them now too. I've been hearing them constantly.
Empathi
I'm sorry to hear about your trouble sleeping and stress. I'm glad you came in, let 07/21/21 9:08 PM E
me learn more about what you're experiencing, and I will try to help.
I appreciate your sympathy.
Questi
Do you ever think people are trying to harm you? 07/21/21 9:09 PM E
They're looking for me, I know it. I don't see them, I don't know why, but I do
know they're following me.
Questi
When did your symptoms start? 07/21/21 9:11 PM E
This week they've been loud, and harsh. They kept telling me to do things I didn't
want to. I just wanted to make them stop so badly, it's scary when it's your own
head, you know? I just wanted to make them stop... I got help before and the
voices quieted down. But they got worse over this past week.
Questi
Did the hallucinations start gradually? 07/21/21 9:12 PM E
The voices got worse and worse over the last week, but they've been there for
years.
Questi
07/21/21 9:12 PM E
Are your hallucinations constant?
Yes, constantly. I hear them constantly. It was getting worse this week, I couldn't
even hear my own thoughts through it all. I told my mom it was bad again last
night, and she brought me in. Questi
07/21/21 9:13 PM E
Can you describe your hallucinations?
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AM Trans…
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