Subjective Data Collection: 37 of 37 (100.0%)
Subjective Data Collection Objective Data Collection Education & Empathy QSEN Competencies
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SBAR
Reflections
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Experts selected these topics as essential components of a strong, thorough interview with this patient.
Patient Data
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A combination of open and closed questions will yie better patient data. The following details are facts o patient's case.
Chief Complaint
Established chief complaint Reports hallucinations Has paranoid thoughts
History of Present Illness
Asked about onset and duration of symptoms Reports hearing voices for the past 7 days
Reports voices have increased over the last week
Reports that voices are currently constant
Asked about characteristics of symptoms Describes voices as sometimes male, sometimes
female
Denies visual hallucinations Denies gustatory hallucinations Denies olfactory hallucinations Denies tactile hallucinations
Followed up on content of hallucinations Reports command hallucinations
Reports resisting doing what the voice say
Asked about aggravating factors of symptoms Reports that voices are more disturbing in quiet
environments (when unable to be distracted)
Asked about coping strategies Reports music as a coping strategy
Past Medical History
Asked about existing health conditions Denies general health conditions
Asked about history of mental health Reports diagnosis of schizophrenia Reports occasional insomnia Denies past history of depression Denies past history of anxiety
Denies past history of bipolar disorder
Followed up on schizophrenia diagnosis Diagnosed age 23
Followed up on insomnia Reports frequent insomnia Reports difficulty falling asleep
Reports recent insomnia has increased [Show Less]