Subjective Data Collection: 16 of 20 (80.0%)
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.Chief Complaint
Finding:
Established chief complaint
Finding:
Reports cough (Found) danny riviera 1 / 3
Pro Tip: Asking about the characteristics of your patient's cough and voice quality should guide your assessment.
Example Question:
Do you have a cough?History of Present Illness
Finding:
Asked about onset of cough
Finding:
Reports cough started 5 days ago (Found) Pro Tip: Whenever you are assessing a symptom or a health condition, inquiring about onset assesses the severity and the progression of the problem.
Example Question:
How long have you had a cough?
Finding:
Asked about frequency and duration of cough
Finding:
Reports coughing every couple minutes (Available) Pro Tip: Establishing a timeline for Danny's coughing will illustrate how long he has been suffering these particular symptoms and might indicate possible triggers.
Example Question:
How frequently have you been coughing?
Finding:
Asked about character of cough 2 / 3
Finding:
Reports cough is wet (Available) Pro Tip: Asking about the characteristics of your patient's cough and voice quality should guide your assessment.
Example Question:
Is your cough a wet cough?
Finding:
Reports clear sputum with cough (Found) Pro Tip: Asking if your patient's cough is productive should guide your assessment.
Example Question:
Do you produce any phlegm or sputum with your cough?
Finding:
Asked about aggravating factors for cough
Finding:
Reports cough is worse at night (Found) Pro Tip: Establishing a timeline for Danny's coughing will illustrate how long he has been suffering these particular symptoms and might indicate possible triggers.
Example Question:
Is your cough worse at night?
Finding:
Reports exposure to secondhand smoke
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