SUBJECTIVE DATA COLLECTION
PATIENT DATA
CHIEF COMPLAINT
Established chief complaint What brings you to the Nurse's office today?
EMPATHIZE
I am sorry you're not feeling well.Can you rate your current pain level on a scale of 0 to 10?
HISTORY OF PRESENT ILLNESS
Asked about onset of cough Asked about frequency and duration of cough When did the cough start?How often are you coughing?How long does the coughing last? 1 / 3
Asked about character of cough Is your cough wet or dry?Do you cough up sputum?Asked about aggravating factors of cough?Do you know what is making the cough worse?Asked about exposure to germs Asked about hand hygiene Asked about cough etiquette Have you been around anyone sick?
EDUCATE
Hand hygiene is very is very important. Make sure to wash your hands with soap and water before, during, and after preparing food, before and after eating food, before and after treating a cut or wound, or after contact with someone who is ill.Do you cover your mouth when you cough?
EDUCATE
It is important to cover your mouth and nose when you cough or sneeze to help stop the spread of germs. 2 / 3
Asked about relieving factors for cough What helps relieve your cough?Followed up on cough medicine What color is the medicine?How often are you taking the cough medicine?
EMPATHIZE
I am sorry to hear that. Thanks for telling me what you know about the medications you take. I will ask your mom for more information.***Patient answers***
EDUCATE
Make sure your mom is present while you are taking your cough medication and your vitamins. It is important to take the correct dosage.Do you take any vitamins or supplements?
EDUCATE
Taking vitamins can be good for you. However, taking too many vitamins can be bad for you. It is best to take the amount of vitamins your mother gives you.
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