Subjective Data Collection
Chief Complaint
-establish chief complaint
-reports feeling excessively weak
-Do you feel weak?
-reports fatigue and sleepiness
-Are you fatigued?
History of Present Illness
-asked about onset and duration of symptoms
-reports symptoms have been happening for pas...
Shadow Health Depression Abigail Harris Subjective Data Collection and Model Documentation Subjective Data Collection Chief Complaint -establish chief complaint -reports feeling excessively weak -Do you feel weak? -reports fatigue and sleepiness -Are you fatigued? History of Present Illness -asked about onset and duration of symptoms -reports symptoms have been happening for past month -How often have you felt fatigue? -reports symptoms have been increasing in the past week -Did the discomfort start gradually? -reports unable to get out of bed every morning -Can you get out of bed? -asked about frequency, duration, and timing of symptoms -reports feeling fatigued every morning -Are you tired in the morning? -reports feeling slightly more energetic in the afternoon -Are you tired in the afternoon? -asked about aggravating factors of symptoms -reports feeling is worse in the morning -When do the symptoms feel worse? -reports no known triggers -What makes your symptoms worse? -asked about treatment and relieving factors of symptoms -reports that lying down feels best when fatigued -What relieves your symptoms? Depression Screening -asked about pleasure and interest in typical activities -reports loss of interest in typical activities -Do you have little interest in doing things? -reports not taking pleasure in things that typically would -Do you not find pleasure in things you used to like? -asked about feeling of depression -denies sadness or depression -Do you feel sad or depressed? -denies feeling hopeless -Do you ever feel hopeless? -asked about sleep -reports light sleep -How much sleep do you get at night? -reports insomnia -Have you ever had insomnia? -reports trouble falling asleep -Do you have trouble falling asleep? -reports trouble staying asleep -Do you have trouble staying asleep? -followed up on frequency of low energy -reports feeling low energy nearly every day
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