focused exam alcohol abuse in progress attempt shadow health nurse admitting note
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PSYCH C487 (PSYCHC487)
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8/31/2018 Focused Exam: Alcohol Abuse | In Progress Attempt | Shadow Health
Focused Exam: Alcohol Abuse (Part 3 of 3)
C487 Psych/Mental Health Clinical - Aug 2018, C487
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Reflections
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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.
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Documentation Review
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Nursing Admitting...
Nursing Admitting Note
Mental Status Note Student Response Model Documentation
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SBAR
aC s
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Chief Complaint right wirst pain following a car accident Ms. Adler has a sprained (R) wrist due to an
MVA caused by impaired driving. She is a self-
harm risk and expressed passive suicidal
ideation.
ed d
ar stu
History of involved in a car accident while under the Rachel Adler is a 20-year-old White woman with
Present Illness influence of alcohol, resulted in right wrist a history of alcohol abuse and anxiety. She was
sh is
sprain brought to the ER last night by law enforcement
after a MVA in which she was noted to be under
Th
the influence of alcohol and had an injured her
(R) wrist. Assessment in the ER confirmed a
sprain of the (R) wrist, and an alcohol level of
0.2% (over the legal limit in the state for
individuals under the age of 21) was
determined at the scene. Ms. Adler stated she
did not know what happened, but was told she
received a ticket for DUI. Reported pain level
upon arrival to the ER to be 8/10. Pain relief
noted when ibuprofen administered. Ms. Adler
denies any nausea, vomiting. Admitted to adult
mental health unit based on positive
assessment for self harm.
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