Subjective Comprehensive Assessment _ Completed _ Shadow Health.

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Comprehensive Assessment Results | Turned In Patient Assessment and Health Literacy - January 2019, NUR 325 Return to Assignment Your Results L La ab b P Pa as ss s Indicates an item that you foun... d. 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. Current Health Status Asked about current health problems Denies current acute health problems Reports diabetes Reports asthma Asked about last visit to a healthcare provider Reports last visit to a healthcare provider was 4 months ago Reports reason for last visit was annual gynecological exam Reports last general physical examination was 5 months ago Asked about current prescription medications Reports taking diabetes medication Reports having an inhaler Reports taking prescription birth control pills Overview Subjective Data Collection: 33 of 33 (100.0%) Transcript Subjective Data Collection Objective Data Collection Documentation Plan My Exam Self-Reflection Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Followed up about diabetes medication Reports diabetes medication is metformin Reports starting taking diabetes medication 5 months ago Reports that side effects of diabetes medication abated over time Reports taking diabetes medication twice daily Reports diabetes medication dose is 850 mg Denies adverse effects of diabetes medication Asked about asthma medication Reports asthma medication has not changed Reports inhaler is albuterol (Proventil) Reports using inhaler no more than 2 times per week Reports recommended dose is 1-3 puffs as needed Reports typically taking 2 puffs Reports sometimes needing 3 puffs to control symptoms Denies adverse effects of asthma medication Followed up about birth control prescription Reports starting birth control 4 months ago Reports reason for birth control was to manage PCOS symptoms Reports birth control is drospirenone and ethinyl estradiol (Yaz) Reports taking birth control pill daily Reports taking birth control pill at the same time every day Denies adverse side effects from birth control Asked about current non-prescription medications Reports occasional ibuprofen use Denies OTC herbals Denies OTC supplements Followed up on ibuprofen (Advil) Reports taking ibuprofen for cramps Reports ibuprofen is regular strength Reports ibuprofen is effective Reports last use of ibuprofen was six weeks ago Asked about allergies Reports allergies have not changed Reports penicillin allergy Reports cat allergy Reports dust allergy Asked about diabetes management through lifestyle Reports recently beginning dieting to manage diabetes Reports recently beginning exercising to manage diabetes Asked about blood glucose monitoring Reports checking blood sugar once a day Reports checking sugar in the morning Reports using glucometer Reports blood sugar number is usually around 90 Reports having adequate supplies Asked about asthma symptoms Denies change in asthma symptoms Reports belief that asthma is wellcontrolled Denies current asthma symptoms Reports last use of Proventil inhaler was yesterday Asked about vision Reports optometrist visit Reports last optometrist visit was 3 months ago Reports recently prescribed eyeglasses Reports that glasses improve overall vision Asked about reproductive system Reports last menstrual period was 2 weeks ago Reports menstrual cycle is normal Reports rare cramping Asked about breast health Reports doing occasional breast exams Denies having a mammogram Denies changes to breasts Denies history of breast cancer Asked about weight changes Reports recent weight loss Reports weight loss of about 10 pounds Psychosocial History Asked about diet Reports a typical breakfast is smoothie with probiotic yogurt or egg on wheat toast with probiotic yogurt [Show More]

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