Documentation
Student Survey
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Patient Data
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Example
Questions
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Reports last exacerbation around cats at
cousin's house
Asked about asthma triggers
Reports cat allergy as asthma trigger
Reports dust as asthma trigger
Denies asthma problems at work
Denies asthma problems at home
Asked asthma management
Reports inhaler
Asked about asthma medication
Reports albuterol inhaler (Proventil)
Reports last inhaler use was three days
ago
Reports using inhaler no more than 2
times per week
Asked about number of puffs when
using asthma inhaler
Reports recommended dose is 1-3 puffs
as needed
Reports typically taking 2 puffs
Reports sometimes needing 3 puffs to
control symptoms
Asked exacerbation symptoms
Reports chest tightness during
exacerbation
Reports wheezing during exacerbation
Reports shortness of breath during
exacerbation
Denies coughing during exacerbation
Denies chest pain during exacerbation
Denies painful breathing
Asked current breathing
Denies current breathing problems
Review of Systems
Asked cough history
Reports only coughing when she has a
cold
Denies coughing up blood
Asked about sputum
Denies sputum
Risk Factors
Asked about respiratory illness history
besides asthma
Denies history of bronchitis
Denies history of pneumonia
Denies history of emphysema
Followed up on asthma diagnosis
Reports specific age of diagnosis is 2.5
years old
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- Fall '14
