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Page 1 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: Asked about chief complaint Finding: Reports headaches (Found) Pro Tip: Use open questions to ask a patient why they're here today so they can tell you in their own words and inform you of the situation. Example Question: Do you have headaches? Finding: Reports excessive weight gain Page 2 (Found) Pro Tip: Use open questions to ask a patient why they're here today so they can tell you in their own words and inform you of the situation. Example Question: Have you had changes to your weight? Finding: Reports swelling (Found) Pro Tip: Use open questions to ask a patient why they're here today so they can tell you in their own words and inform you of the situation. Example Question: Do you have swelling anywhere? Finding: Reports test results the physician said were problematic (Found) Pro Tip: Use open questions to ask a patient why they're here today so they can tell you in their own words and inform you of the situation. Example Question: What did the physician say about your test results? Patient Comfort Finding: Asked about patient comfort Page 4 (Found) Pro Tip: Ask patients everything you can about their current illness, from its characteristics to its frequency to its causes, so you can determine its nature and what treatments are recommendable. Example Question: What were the results of your high blood pressure tests? Finding: Reports moderately high blood pressure 1 week ago (Found) Pro Tip: Ask patients everything you can about their current illness, from its characteristics to its frequency to its causes, so you can determine its nature and what treatments are recommendable. Example Question: What were the results of your high blood pressure tests? Finding: Reports urinalysis showed proteinuria (Found) Pro Tip: Ask patients everything you can about their current illness, from its characteristics to its frequency to its causes, so you can determine its nature and what treatments are recommendable. Example Question: What were the results of your urine tests? Finding: Asked about duration of symptoms Page 5 Finding: Reports excessive swelling started a week ago (Found) Pro Tip: Ask patients everything you can about their current illness, from its characteristics to its frequency to its causes, so you can determine its nature and what treatments are recommendable. Example Question: When did your swelling start? Finding: Reports weight gain occurred over last month (Found) Pro Tip: Ask patients everything you can about their current illness, from its characteristics to its frequency to its causes, so you can determine its nature and what treatments are recommendable. Example Question: When did your weight gain start? Finding: Reports headaches starting 4 or 5 days ago (Found) Pro Tip: Ask patients everything you can about their current illness, from its characteristics to its frequency to its causes, so you can determine its nature and what treatments are recommendable. Example Question: When did your headaches start? Page 7 Reports headaches occur daily (Found) Pro Tip: Ask patients everything you can about their current illness, from its characteristics to its frequency to its causes, so you can determine its nature and what treatments are recommendable. Example Question: How often do you get headaches? Finding: Asked about vision disturbances Finding: Denies vision disturbances (Available) Pro Tip: Ask patients everything you can about their current illness, from its characteristics to its frequency to its causes, so you can determine its nature and what treatments are recommendable. Example Question: Do you have vision disturbances? Finding: Asked about aggravating factors for headaches Finding: Denies aggravating factors (Found) Page 8 Pro Tip: Ask patients everything you can about their current illness, from its characteristics to its frequency to its causes, so you can determine its nature and what treatments are recommendable. Example Question: Does anything aggravate your headaches? Finding: Asked about relieving factors for headaches Finding: Reports Tylenol temporarily alleviates headaches (Found) Pro Tip: Ask patients everything you can about their current illness, from its characteristics to its frequency to its causes, so you can determine its nature and what treatments are recommendable. Example Question: Do you take anything for headaches? Finding: Asked about pain rating Finding: Reports headache pain at worst is a 3 out of 10 (Found) Pro Tip: Ask patients everything you can about their current illness, from its characteristics to its frequency to its causes, so you can determine its nature and what treatments are recommendable. Page 10 Finding: Reports feet and ankles look and feel swollen (Available) Pro Tip: Ask patients everything you can about their current illness, from its characteristics to its frequency to its causes, so you can determine its nature and what treatments are recommendable. Example Question: Where do you have swelling? Finding: Reports hands and fingers feel slightly swollen (Available) Pro Tip: Ask patients everything you can about their current illness, from its characteristics to its frequency to its causes, so you can determine its nature and what treatments are recommendable. Example Question: Where do you have swelling? Finding: Reports wearing flip flops and slippers for comfort (Available) Pro Tip: Ask patients everything you can about their current illness, from its characteristics to its frequency to its causes, so you can determine its nature and what treatments are recommendable. Example Question: What do you do for the swelling? Page 11 Finding: Reports swollen joints feel tight (Found) Pro Tip: Ask patients everything you can about their current illness, from its characteristics to its frequency to its causes, so you can determine its nature and what treatments are recommendable. Example Question: What does the swelling feel like? Finding: Asked about checking blood pressure at home Finding: Denies checking blood pressure at home (Found) Pro Tip: Ask patients everything you can about their current illness, from its characteristics to its frequency to its causes, so you can determine its nature and what treatments are recommendable. Example Question: Do you check your blood pressure at home? Past Medical History Finding: Asked about preexisting medical conditions Page 13 Denies having seasonal allergies (Found) Pro Tip: Asking patients about their past medical history can help contextualize their current illness and inform you of health considerations that need to be made for this visit. Example Question: Do yau have any seasonal allergies? Finding: Denies having food allergies (Found) Pro Tip: Asking patients about their past medical history can help contextualize their current illness and inform you of health considerations that need to be made for this visit. Example Question: Do you have any food allergies? Finding: Denies having latex allergy (Found) Pro Tip: Asking patients about their past medical history can help contextualize their current illness and inform you of health considerations that need to be made for this visit. Example Question: Do you have a latex allergy? Finding: Page 14 Denies having medicine allergies (Found) Pro Tip: Asking patients about their past medical history can help contextualize their current illness and inform you of health considerations that need to be made for this visit. Example Question: Do you have any medication allergies? Home Medications Finding: Followed up on home medications Finding: Denies taking home medications other than Tylenol (Found) Pro Tip: Asking a patient what medications they take at home can help you understand their health, what requires medication, and how the variations in prescriptions may be affecting symptoms. Example Question: Do you take medication besides Tylenol? Finding: Reports taking Tylenol daily (Found) Pro Tip: Asking a patient what medications they take at home can help you understand their health, what requires medication, and how the variations in prescriptions may be affecting symptoms. Page 16 Example Question: How long have you been taking Tylenol? Finding: Asked about vitamins Finding: Reports taking iron-based prenatal vitamins (Found) Pro Tip: Asking a patient what medications they take at home can help you understand their health, what requires medication, and how the variations in prescriptions may be affecting symptoms. Example Question: Do you take vitamins? Reproductive History Finding: Asked about other pregnancy complications Finding: Denies other pregnancy complications (Found) Pro Tip: Asking a pregnant person about their history in this pregnancy and those prior can inform your current understanding of their health. Example Question: Page 17 Have you had any other pregnancy complications? Finding: Asked about prior pregnancies Finding: Denies prior pregnancies (Found) Pro Tip: Asking a pregnant person about their history in this pregnancy and those prior can inform your current understanding of their health. Example Question: Have you been pregnant before this? Finding: Asked about prenatal visits Finding: Reports attending all recommended OB visits (Found) Pro Tip: Asking a pregnant person about their history in this pregnancy and those prior can inform your current understanding of their health. Example Question: Do you ever miss prenatal visits? Finding: Page 19 Social History Finding: Asked about alcohol intake Finding: Reports drinking socially prior to pregnancy (Found) Pro Tip: A patient's social history encompasses their whole lifestyle, from diet and exercise, to substance use, to home and work life. Ask a patient a myriad of these questions to understand how a patient's behaviors are affecting their health. Example Question: Did you drink alcohal before your pregnancy? Finding: Denies alcohal consumption since discovering pregnancy at 5 weeks (Found) Pro Tip: A patient's social history encompasses their whole lifestyle, from diet and exercise, to substance use, to home and work life. Ask a patient a myriad of these questions to understand how a patient's behaviors are affecting their health. Example Question: Have you drank alcohol while pregnant? Finding: Asked about tobacco use Page 20 Finding: Denies using tobacco products (Found) Pro Tip: A patient's social history encompasses their whole lifestyle, from diet and exercise, to substance use, to home and work life. Ask a patient a myriad of these questions to understand how a patient's behaviors are affecting their health. Example Question: Do you use tobacco products? Finding: Asked about illicit drug use Finding: Denies illicit drug use (Found) Pro Tip: A patient's sacial history encompasses their whole lifestyle, from diet and exercise, to substance use, to home and work life. Ask a patient a myriad of these questions to understand how a patient's behaviors are affecting their health. Example Question: Do you use illicit drugs? Finding: Asked about occupation 
