DOCSITY

Review of Systems Head: Reports headaches that occur weekly with reading in the past year. The headache lasts a few hours and is relieved with acetaminophen and sleep. Headaches are described as a "tight and throbbing feeling behind the eyes." Denies head and neck trauma. Ears: Denies difficulty hearing, tinnitus, ear pain, and discharge. Eyes: Complains of blurred vision associated with "reading and studying," which has worsened over the past few years. No visual acuity testing s...

All the best from Dr. A Dr. Assessments Page 1 of 10 What brings you in today?? Reports frequently occurring stomach pain How long have you had stomach pain? Noticing pain for at least a month Did the pain start suddenly? Pain increased gradually Do you have stomach pain every day? Reports pain daily How many times a week does your stomach hurt? Reports 3-4 episodes a week that are more severe How long after a meal does the pain start? Right after finishing a meal How many hours do...

All the best from Dr. A Dr. Assessments Page 1 of 3 Chief Complaint Ms. Abigail Harris is an 86-year-old African American woman who presented in the ED with weakness and fatigue. History of Present Illness Reports weakness and fatigue for last month, increasing over last 7 days. Ms. Harris is occasionally unable to get out of bed in the morning. The timing of fatigue is every morning. Reports that her fatigue is somewhat alleviated by lying down, and that she has slightly more energy in...

Bedside Shift Report Holly: Mr. Liu, this is your new nurse. They'll be taking over for me. Samuel: Hello. Nice to meet you. I'll be checking in with you every hour or so. Holly: All right, Mr. Liu, I'm going to hand you off to your new nurse using a Bedside Shift Report. At Shadow General, we perform our handoffs at the patient's bedside to make sure that you can stay involved in your care. Samuel: Sounds good. Holly: OK, I'm going to start with Mr. Liu's Situation . . . Holly:...

Established chief complaint? Reports cough Asked about onset of cough? Reports cough started 3 days ago Asked about characteristics of cough? Reports cough is wet Reports clear sputum with cough Asked about frequency and duration of cough? Reports coughing every few minutes Reports coughs last a few seconds Asked about aggravating factors for cough? Reports cough is worse at night Denies smoking Reports being exposed to secondhand smoke through father Reports he doesn't know what ...

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 pill...

Established chief complaint? Reports chest pain Asked about onset and duration of chest pain? Reports chest pain started about five minutes ago Reports chest pain has been constant since it began Reports sitting in bed when pain began Asked to rate chest pain on a scale? Reports current pain is 6/10 Asked about on characteristics of the pain? Describes pain as tight and uncomfortable Denies crushing pain Denies gnawing or tearing pain Denies burning pain Asked about location of the ...

"What is this?"; Let the patient know which medication you are giving & what it is intended to treat. Model Response: This is lisinopril, which you are getting to help control your high blood pressure. "I guess I'm not supposed to take this with food. Is that right?"; This is an opportunity to teach the patient whether this medication should be taken with food. Model Response: Lisinopril can actually be taken with or without food, whatever fits your routine best. What is most importa...

What is the most appropriate response to Anita in this situation? Why is this the best response to Anita's concern? I hear and understand what you are saying. We'll certainly do what we can to make sure you don't stay any longer than you have to! The provider didn't say you were ready to be discharged today, but I can bring up your concerns with him today. In the meantime, why don't we discuss your feelings further? This answer reiterates that a nurse is not able to decide if a patie...

How will you respond to Charge Nurse Angela's request? Why have you accepted an appropriate level of responsibility? That works for me. I'll let you know how it goes. All Shadow General staff are expected to be change agents, no matter the situation or the ranking of the parties involved. How should you respond? Which statement, regarding best practice on the ongoing education of staff, is most correct? Sounds good. I'll talk with Ben soon about practicing the SBAR. Staff education i...