question archive Week 4 Shadow Health Digital Clinical Experience Health History Documentation SUBJECTIVE DATA: Include what the patient tells you, but organize the information
Week 4 Shadow Health Digital Clinical Experience Health History Documentation SUBJECTIVE DATA: Include what the patient tells you, but organize the information
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Week 4
Shadow Health Digital Clinical Experience Health History Documentation
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC):
History of Present Illness (HPI):
Medications:
Allergies:
Past Medical History (PMH):
Past Surgical History (PSH):
Sexual/Reproductive History:
Personal/Social History:
Immunization History:
Health Maintenance:
Significant Family History (Include history of parents, maternal/paternal Grandparents, siblings, and children):
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History). Remember that the information you include in this section is based on what the patient tells you. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.
General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Psychiatric:
Neurological:
Skin:
Hematologic:
Endocrine:
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21
Walden University
Page
1
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2
Name:
Section:
Week 4
Shadow Health Digital Clinical Experience Health History Documentation
SUBJECTIVE DATA:
Include what the patient tells you, but organize the information.
Chief Complaint (CC):
History of Present Illness
(HPI):
Medications:
Allergies:
Past Medical History (PMH):
Past Surgical History (PSH):
Sexual/Reproductive History:
Personal/Social History:
Immunization History:
Health Maintenance:
Significant Family History (
Include history of parents,
maternal/p
aternal
Grandparents, siblings,
and children):
Review of Systems:
From head
-
to
-
toe, include each system that covers the Chief Complaint,
History of Present Illness, and History).
Remember that the information you include in this
section is based on what t
he patient tells you. To ensure that you include all essentials in your
case, refer to Chapter 2 of the Sullivan text.
General:
Include any recent weight changes, weakness, fatigue, or fever, but
do not
restate HPI data here
.
HEENT:
Neck:
© 2021 Walden University Page 1 of 2
Name:
Section:
Week 4
Shadow Health Digital Clinical Experience Health History Documentation
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC):
History of Present Illness (HPI):
Medications:
Allergies:
Past Medical History (PMH):
Past Surgical History (PSH):
Sexual/Reproductive History:
Personal/Social History:
Immunization History:
Health Maintenance:
Significant Family History (Include history of parents, maternal/paternal Grandparents, siblings,
and children):
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint,
History of Present Illness, and History). Remember that the information you include in this
section is based on what the patient tells you. To ensure that you include all essentials in your
case, refer to Chapter 2 of the Sullivan text.
General: Include any recent weight changes, weakness, fatigue, or fever, but do not
restate HPI data here.
HEENT:
Neck:c
