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Patient Status
Shadow 3 Health documentation
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.
Finding:
Assessed patient status
Finding:
Reports feeling "way better"
(Found)
Pro Tip: Assessing a pediatric patient's status involves asking about their current comfort, needs, and chief complaint. It's important to check in with a patient's status, because it may reveal insight into their current condition.
Example Question:
How do you feel?
Finding:
Reports eagerness to go home
(Found)
Pro Tip: Assessing a pediatric patient's status involves asking about their current comfort, needs, and chief complaint. It's important to check in with a patient's status, because it may reveal insight into their current condition.
Example Question:
How do you feel?
Finding:
Asked about patient's comfort
Finding:
Reports feeling comfortable
(Available)
Pro Tip: Assessing a pediatric patient's status involves asking about their current comfort, needs, and chief complaint. It's important to check in with a patient's status, because it may reveal insight into their current condition.
Example Question:
Are you having pain right now?
Finding:
Asked about patient's needs
Finding:
present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Why were you admitted?
Finding:
Reports vomiting
(Found)
Pro Tip: Asking a pediatric patient about the duration and onset of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Why were you admitted?
Finding:
Asked about patient's other symptoms prior to DKA
Finding:
Reports frequent urination prior to DKA
(Found)
Pro Tip: Asking a pediatric patient about the duration and onset of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Have you been urinating more often than usual?
Finding:
Reports excessive thirst prior to DKA
(Found)
Pro Tip: Asking a pediatric patient about the duration and onset of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Have you been feeling more thirsty lately?
Finding:
Reports fatigue prior to DKA
(Found)
Pro Tip: Asking a pediatric patient about the duration and onset of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Are you always fatigued?
Finding:
Reports lack of appetite prior to DKA
(Found)
Pro Tip: Asking a pediatric patient about the duration and onset of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Finding:
Asked about diet at mother's house
Finding:
Reports mother is a "health nut"
(Available)
Pro Tip: Assessing a pediatric patient's diet solicits information relevant to their current diagnosis that informs you of potential aggravating and relieving factors of their chief complaint. Details of their current diet will help you to educate the patient on a diet that will help in the treatment and management of their condition.
Example Question:
What is your diet like?
Finding:
Reports typical breakfast at mother's home is yogurt and fruit
(Found)
Pro Tip: Assessing a pediatric patient's diet solicits information relevant to their current diagnosis that informs you of potential aggravating and relieving factors of their chief complaint. Details of their current diet will help you to educate the patient on a diet that will help in the treatment and management of their condition.
Example Question:
What's your usual breakfast?
Social History Patient
Finding:
Reports typical lunch is a salad with chicken
(Found)
Pro Tip: Assessing a pediatric patient's diet solicits information relevant to their current diagnosis that informs you of potential aggravating and relieving factors of their chief complaint. Details of their current diet will help you to educate the patient on a diet that will help in the treatment and management of their condition.
Example Question:
What do you usually eat for lunch?
Finding:
Reports typical dinner is grilled meat and vegetables
(Found)
Pro Tip: Assessing a pediatric patient's diet solicits information relevant to their current diagnosis that informs you of potential aggravating and relieving factors of their chief complaint. Details of their current diet will help you to educate the patient on a diet that will help in the treatment and management of their condition.
Example Question:
What's a typical dinner?
Finding:
Asked about social activities
Finding:
Reports riding horses 2-3 times a week after school
Review of Relevant Systems Patient
important to ask about sexual activity and substance use. These factors can influence their current health and wellness. Asking about a pediatric patient's social history can also unveil the influence of their present illnesses in their social lives.
Example Question:
Have you ever vaped or used an ecigarette?
Finding:
Denies alcohol use
(Found)
Pro Tip: A pediatric patient's social history encompasses their family and support system, living situation, and daily behaviors such as diet and exercise. Even though you are working with pediatric patients, it is important to ask about sexual activity and substance use. These factors can influence their current health and wellness. Asking about a pediatric patient's social history can also unveil the influence of their present illnesses in their social lives.
Example Question:
Do you drink alcohol?
Finding:
Asked about general symptoms
Finding:
Denies current excessive thirst
(Found)
Pro Tip: Understanding a pediatric patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you been feeling more thirsty lately?
Finding:
Asked about gastrointestinal symptoms
Finding:
Denies current nausea
(Found)
Pro Tip: Understanding a pediatric patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Did your nausea improve?
Finding:
Denies current vomiting
(Found)
Pro Tip: Understanding a pediatric patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Are you going to be sick?
Confirmed Guardian's Relationship
Example Question:
Do you urinate a lot?
Finding:
Asked about neurological system
Finding:
Denies neurological symptoms
(Found)
Pro Tip: Understanding a pediatric patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you feel tingling anywhere?
Finding:
Confirmed guardian's relationship to patient
Finding:
Reports he is patient's father
(Found)
History of Present Illness Guardian
Pro Tip: Determining the guardian's relationship to a pediatric patient confirms the appropriate family members are present. Knowing who is with the pediatric patient will help you to develop the best approach to gathering information on the patient's condition.
Example Question:
what is your relationship to the patient
Finding:
Asked about patient's diagnosis
Finding:
Reports patient is diagnosed with type 1 diabetes
(Found)
Pro Tip: Asking a pediatric patient's guardian about the duration and onset of the patient's current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
What is your daughter's diagnosis
Finding:
Followed up on history of present illness leading to diagnosis
Finding:
Reports patient was admitted to hospital two days prior
(Found)
Pro Tip: Asking a pediatric patient's guardian about the duration and
How was your daughter feeling?
Finding:
Reports taking daughter to ED when he realized she was "out of it"
(Found)
Pro Tip: Asking a pediatric patient's guardian about the duration and onset of the patient's current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
How was your daughter feeling?
Finding:
Asked about patient's symptoms prior to DKA
Finding:
Reports weight loss
(Found)
Pro Tip: Asking a pediatric patient's guardian about the duration and onset of the patient's current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Has your daughter's weight changed lately?
Finding:
Followed up on weight loss
Assess Guardian Knowledge
Finding:
Reports patient lost 5 pounds
(Available)
Pro Tip: Asking a pediatric patient's guardian about the duration and onset of the patient's current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
How much weight has your daughter lost?
Finding:
Reports weight loss happened in the two weeks since he last saw the patient
(Available)
Pro Tip: Asking a pediatric patient's guardian about the duration and onset of the patient's current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
How much weight has your daughter lost?
Finding:
Assessed knowledge of type 1 diabetes
Finding:
Reports knowledge of type 1 diabetes
(Found)
What does your daughter usually eat for lunch?
Finding:
Reports going out to dinner often
(Found)
Pro Tip: Asking a pediatric patient's guardian about their diet solicits information relevant to their current diagnosis that informs you of potential aggravating and relieving factors of their current chief complaint. Details of their current diet will help you to educated the guardian on a diet that will help in the treatment and management of their condition.
Example Question:
What does your daughter usually eat for dinner?
Finding:
Denies knowledge of high carb intake
(Found)
Pro Tip: Asking a pediatric patient's guardian about their diet solicits information relevant to their current diagnosis that informs you of potential aggravating and relieving factors of their current chief complaint. Details of their current diet will help you to educated the guardian on a diet that will help in the treatment and management of their condition.
Example Question:
How many carbohydrates does your daughter eat a day
Finding:
Reports belief in a low sugar intake
(Found)
Pro Tip: Asking a pediatric patient's guardian about their diet solicits information relevant to their current diagnosis that informs you of potential aggravating and relieving factors of their current chief complaint. Details of their current diet will help you to educated the guardian on a
Social History Guardian
diet that will help in the treatment and management of their condition.
Example Question:
How many carbohydrates does your daughter eat a day
Finding:
Asked guardian about social history
Finding:
Reports being divorced from patient's mom
(Found)
Pro Tip: A patient's and their guardian's social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, and substance use. These factors can influence their current health and wellness. Asking a guardian about a pediatric patient's social history can also unveil the influence of their present illnesses on their social lives.
Example Question:
Are you married?
