Scott Becker shadow health Subjective Data Collection
Scott Becker shadow health Subjective Data Collection
Subjective Data Collection: 26 of 26 (100.0%)
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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
Found:
Indicates an item that you found.
Available:
Indicates an item that is available to be found.
Category
Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
Patient Data
Not Scored
A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.
Patient Check In
Finding:
Asked about chief complaint
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Finding:
Reports fatigue
(Found)
Pro Tip: By asking a patient an open question about their reason for coming into the hospital, you can establish their current medical and comfort needs and assist in coordinating their care.
Example Question:
What brings you to the hospital?
Finding:
Reports small amount of blood in vomit
(Found)
Pro Tip: By asking a patient an open question about their reason for coming into the hospital, you can establish their current medical and comfort needs and assist in coordinating their care.
Example Question:
What brings you to the hospital?
Finding:
Reports stomach pain
(Found)
Pro Tip: By asking a patient an open question about their reason for coming into the hospital, you can establish their current medical and comfort needs and assist in coordinating their care.
Example Question:
What brings you to the hospital? Scott Becker shadow health Subjective Data Collection
History of Present Illness
Finding:
Followed up on fatigue
Finding:
Reports worsening fatigue over several weeks
(Found)
Pro Tip: Details of a patient’s current complaint will help you follow up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
How long have you felt fatigued?
Finding:
Followed up on vomit
Finding:
Reports vomiting only once
(Found)
Pro Tip: Details of a patient’s current complaint will help you follow up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
How often have you been vomiting?
Finding:
Reports vomiting this morning
(Found)
Pro Tip: Details of a patient’s current complaint will help you follow up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
When did you vomit?
Finding:
Reports noticing dark flecks in vomit
(Available)
Pro Tip: Details of a patient’s current complaint will help you follow up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
What was your vomit like?
Finding:
Followed up on stomach pain
Finding:
Reports pain in upper-left abdomen Scott Becker shadow health Subjective Data Collection
(Found)
Pro Tip: Details of a patient’s current complaint will help you follow up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Where is your stomach pain?
Finding:
Reports stomach pain is gnawing or burning
(Found)
Pro Tip: Details of a patient’s current complaint will help you follow up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
How would you describe the stomach pain?
Finding:
Reports experiencing stomach pain for past 3 to 4 months
(Found)
Pro Tip: Details of a patient’s current complaint will help you follow up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
How long have you had stomach pain?
Finding:
Reports stomach pain worsens after eating
(Found)
Pro Tip: Details of a patient’s current complaint will help you follow up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Does the pain get better or worse after eating?
Finding:
Reports stomach pain increasing over the past week
(Found)
Pro Tip: Details of a patient’s current complaint will help you follow up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Has your stomach pain gotten worse over time?
Finding:
Reports taking antacids daily Scott Becker shadow health Subjective Data Collection
(Found)
Pro Tip: Details of a patient’s current complaint will help you follow up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Do you take anything for your stomach pain?
Finding:
Reports antacids are moderately effective
(Found)
Pro Tip: Details of a patient’s current complaint will help you follow up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Does anything relieve your stomach pain?
Past Medical History
Finding:
Asked about allergies
Finding:
Denies food allergies
(Available)
Pro Tip: A patient’s past medical history includes their health conditions, what preventive and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.
Example Question:
Do you have any food allergies?
Finding:
Denies environmental allergies
(Found)
Pro Tip: A patient’s past medical history includes their health conditions, what preventive and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.
Example Question:
Do you have any environmental allergies?
Finding:
Denies latex allergy
(Available)
Pro Tip: A patient’s past medical history includes their health conditions, what preventive and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.
Example Question:
Are you allergic to latex?
Finding:
Denies medication allergies
(Found)
Pro Tip: A patient’s past medical history includes their health conditions, what preventive and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.
Example Question:
Do you have any medication allergies?
Finding:
Asked about existing health conditions
Finding:
Reports hypertension
(Found)
Pro Tip: A patient’s past medical history includes their health conditions, what preventive and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.
Example Question:
Do you have any existing health conditions?
Finding:
Reports high cholesterol
(Found)
Pro Tip: A patient’s past medical history includes their health conditions, what preventive and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.
Example Question:
Do you have any existing health conditions?
Finding:
Reports coronary artery disease
(Found)
Pro Tip: A patient’s past medical history includes their health conditions, what preventive and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.
Example Question:
Do you have any existing health conditions?
Finding:
Reports osteoarthritis
(Found)
Pro Tip: A patient’s past medical history includes their health conditions, what preventive and maintenance treatments they have received, and any previous medical interventions they have received. Asking about a patient’s medical history helps you contextualize their current health for proper assessment.
Example Question:
Do you have any existing health conditions?
Social History
Finding:
Asked about living situation
Finding:
Reports living with family
(Found)
Pro Tip: A patient’s social history encompasses a patient’s social, cultural, economic, and lifestyle factors that together influence the patient’s health. Asking a patient about subjects such as common lifestyle activities and substance use can help you gain understanding about a patient’s social history.
Example Question:
What is your living situation?
GET SHADOW HEALTH HELP HERE
Finding:
Asked about tobacco use
Finding:
Denies tobacco use
(Found)
Pro Tip: A patient’s social history encompasses a patient’s social, cultural, economic, and lifestyle factors that together influence the patient’s health. Asking a patient about subjects such as common lifestyle activities and substance use can help you gain understanding about a patient’s social history.
Example Question:
Do you use any tobacco products?
Finding:
Asked about caffeine use
Finding:
Reports drinking coffee
(Found)
Pro Tip: A patient’s social history encompasses a patient’s social, cultural, economic, and lifestyle factors that together influence the patient’s health. Asking a patient about subjects such as common lifestyle activities and substance use can help you gain understanding about a patient’s social history.
Example Question:
Do you consume caffeine?
Finding:
Reports drinking coffee every morning
(Found)
Pro Tip: A patient’s social history encompasses a patient’s social, cultural, economic, and lifestyle factors that together influence the patient’s health. Asking a patient about subjects such as common lifestyle activities and substance use can help you gain understanding about a patient’s social history.
Example Question:
How often do you drink coffee?
Finding:
Reports drinking 2 to 3 cups
(Found)
Pro Tip: A patient’s social history encompasses a patient’s social, cultural, economic, and lifestyle factors that together influence the patient’s health. Asking a patient about subjects such as common lifestyle activities and substance use can help you gain understanding about a patient’s social history.
Example Question:
How many cups of coffee do you have in a day?
Finding:
Asked about alcohol use
Finding:
Reports alcohol use
(Found)
Pro Tip: A patient’s social history encompasses a patient’s social, cultural, economic, and lifestyle factors that together influence the patient’s health. Asking a patient about subjects such as common lifestyle activities and substance use can help you gain understanding about a patient’s social history.
Example Question:
Do you drink alcohol?
Finding:
Reports drinking 1 to 2 nights a week
(Found)
Pro Tip: A patient’s social history encompasses a patient’s social, cultural, economic, and lifestyle factors that together influence the patient’s health. Asking a patient about subjects such as common lifestyle activities and substance use can help you gain understanding about a patient’s social history.
Example Question:
How often do you drink alcohol?
Finding:
Reports having 1 to 2 glasses per sitting
