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Focused Exam Alcohol Abuse Completed Shadow Health subjective
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8/31/2018 Focused Exam: Alcohol Abuse | Completed | Shadow HealthFocused Exam: Alcohol Abuse Results | Turned In
C487 Psych/Mental Health Clinical - Aug 2018, C487
Return to Assignment
Your Results Reopen Lab Pass
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Subjective Data Collection: 51 of 51 (100.0%)
er as
Overview
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Transcript
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Subjective Data Collection Hover To Reveal...
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Indicates an item that you found.
Objective Data Collection
rs e Hover over the Patient Data items Indicates an item that is available to be
ou urc
below to reveal important information, found.
including Pro Tips and Example
Education & Empathy
Questions.
QSEN Competencies
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Catego Scored Items Patient Data
aC s
Documentation
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Not Scored
SBAR
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Experts selected these topics as essential A combination of open and closed questions
Overview video
components of a strong, thorough interview will yield better patient data. The following
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with this patient. details are facts of the patient's case.
Reflections
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Chief Complaint
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Established chief complaint and reason Reports car accident
for admittance Reports injury
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Reports passive suicidal ideation
History of Present Illness
Followed up on details of car accident Reports loss of consciousness
Reports being unsure of how the accident
happened
Reports wearing seatbelt
Reports being the driver - no other
passengers in car
Reports was told she would get a ticket for
DUI
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, 8/31/2018 Focused Exam: Alcohol Abuse | Completed | Shadow Health
Followed up on alcohol use just prior to Reports drinking before accident
car accident Reports being unsure of how many drinks
- "at least 5"
Reports was drinking with friends at a
party
Reports left party to drive home because
she was mad at her girlfriend and could not
take any more
Asked about driving impaired Reports knew she was driving under the
influence but did not care
Reports have driven in past after drinking,
but this time she did not care if she injured
herself
Followed up on impaired driving - risk for Reports has had enough of life and did not
self harm care if she got hurt/died
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Reports had not thought about self harm
before accident
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Reports since accident, not sure what to
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think about what she did
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Asked about onset and duration of pain Reports pain started immediately after
accident
Reports accident was last night
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Reports accident was at 10 pm
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Asked about location of pain Reports pain is in right wrist
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Asked about aggravating factors of pain Reports increased pain when bending or
twisting (R) wrist
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Reports increased pain when trying to lift
items, even small ones such as a hairbrush
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Asked about treatment and relieving Reports rest improves pain
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factors of pain Reports ibuprofen has significantly
reduced pain
Reports wearing sling helps
Asked about characteristics of pain Reports pain is aching
Denies sharp or shooting pain
Asked about severity of pain Reports current pain level is 2/10
Reports pain without medication was 8/10
Past Medical History
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