Exam (elaborations)
Shadow Health Comprehensive Assessment
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Shadow Health Comprehensive Assessment/Shadow Health Comprehensive Assessment
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Subjective Data Collection: 33 of 33 (100.0%)Hover To Reveal...
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.
Current Health Status
Finding:
Asked about current health problems
Finding:
Denies current acute health problems
(Found)
Pro Tip: Determining if the patient has any current acute health problems is essential in conducting a
productive exam and prioritzing the patient's needs.
Example Question:
Are you having any health problems?
Finding:
Reports diabetes
(Found)
,Pro Tip: Confirming a patient's medical conditions, such as diabetes, will enable you to provide the best
care possible.
Example Question:
Can you confirm your diabetes?
Finding:
Reports asthma
(Found)
Pro Tip: Confirming a patient's medical conditions, such as asthma, will enable you to provide the best
care possible.
Example Question:
Can you confirm your asthma?
Finding:
Asked about last visit to a healthcare provider
Finding:
Reports last visit to a healthcare provider was 4 months ago
(Found)
Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a
comprehensive health history.
Example Question:
When did you see a healthcare provider?
Finding:
Reports reason for last visit was annual gynecological exam
(Found)
Pro Tip: Establishing a timeline for Tina's gynecological exams will allow you to develop a comprehensive
health history.
Example Question:
Why did you see a healthcare provider?
Finding:
Reports last general physical examination was 5 months ago
(Available)
,Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a
comprehensive health history.
Example Question:
When was your last physical exam?
Finding:
Asked about current prescription medications
Finding:
Reports taking diabetes medication
(Found)
Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy,
and current treatment plans. Asking Tina if she has been taking medication for her diabetes will indicate
her treatment plan and the degree to which she is following it.
Example Question:
Have you been taking medication for your diabetes?
Finding:
Reports having an inhaler
(Found)
Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy,
and current treatment plans. Asking Tina if she still has her inhaler will indicate her treatment plan and
the degree to which she is following it.
Example Question:
Do you have an inhaler?
Finding:
Reports taking prescription birth control pills
(Found)
Pro Tip: A patient's use of birth control can impact the care plan, such as which medications are
prescribed. Understanding a patient's history of birth control can be an indicator of health literacy.
Example Question:
Are you taking any form of birth control?
Finding:
Followed up about diabetes medication
, Finding:
Reports diabetes medication is metformin
(Found)
Pro Tip: Follow up questions about Tina's diabetes medication will help you to understand her treatment
plan and recent health history.
Example Question:
What is the name of your diabetes medication?
Finding:
Reports starting taking diabetes medication 5 months ago
(Available)
Pro Tip: Follow up questions about Tina's diabetes medication history and timeline will help you to
understand her treatment plan and recent health history.
Example Question:
How long have you been taking metformin?
Finding:
Reports that side effects of diabetes medication abated over time
(Available)
Pro Tip: Determining if Tina has experienced any side effects of her diabetes medication will help you
determine the efficacy and appropriateness of her medication.
Example Question:
Have you noticed any side effects from the metformin?
Finding:
Reports taking diabetes medication twice daily
(Found)
Pro Tip: Follow up questions about Tina's medication adherence will help you to understand her
treatment plan and recent health history.
Example Question:
How many times a day do you take metformin?
Finding:
Reports diabetes medication dose is 850 mg
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