TJ HEENT.docx - Subjective Data Collection 34 of 34(100.0...

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Subjective Data Collection: 34 of 34 (100.0%) 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. Relevant Medical History Finding: Asked about head problems Finding: Reports occasional headaches (Found) Pro Tip: Headaches can be caused a variety of ways, such as when sinus problems result in increased pressure buildup. Asking Tina if she gets headaches is soliciting information about possible symptoms that she experiences. Example Question:
Do you get headaches? Finding: Denies current headache (Found) Pro Tip: Assessing how a patient feels in the current moment can allow you to juxtapose their chief complaint alongside symptoms they experience. Asking Tina if she currently has a headache solicits information about how she is feeling now. Example Question: Do you currently have a headache? Finding: Denies head problems other than headaches (Found) Pro Tip: Broad, open questions will allow Tina to describe, in her own words, any specific head conditions and symptoms that she is experiencing. Example Question: Other than headaches, are you experiencing head problems? Finding: Asked about frequency of headaches Finding: Reports headaches occur once a week (Found) Pro Tip: Establishing a timeline for how often Tina gets headaches will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers. Example Question:
How frequently do your headaches occur? Finding: Asked about duration of headaches Finding: Reports headaches last a few hours (Found) Pro Tip: Establishing a timeline for how long Tina's headaches last will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers. Example Question: How long do your headaches last? Finding: Asked about character and location of headaches Finding: Reports headaches as tight and throbbing (Found) Pro Tip: Specifying what the pain feels like can narrow and define the type of headache Tina is experiencing. Soliciting this information allows you to more accurately treat her symptoms. Example Question: What do your headaches feel like? Finding: Reports headache located behind her eyes (Found)
Pro Tip: Specifying the location of Tina's pain can narrow and define where Tina's pain is occurring. Soliciting this information allows you to more accurately treat her symptoms.

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