Health History Results | Turned In
Health Assessment Laboratory - Fall 2019, NUR 305L
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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.
Chief Complaint
Established chief complaint Reports pain
Reports foot wound
History of Presenting Illness
Asked to rate current pain level on a
scale
Reports current pain is 7/10
Asked for details about the pain Reports pain is throbbing
Reports pain is sharp when she attempts
to stand
Reports pain has increased in the past 2
days
Reports feeling pain radiating into ankle
Subjective Data Collection: 52 of 88 (59.1%) Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Information Processing
Health History Tips and Tricks
Self-Reflection
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Hover over the Patient Data items
below to reveal important
information, including Pro Tips and
Example Questions.
Reports pain prevents bearing weight on
foot
Asked location of wound Reports right foot is injured
Reports wound is on the plantar surface
of her foot
Asked details of the injury Reports she scraped foot on bottom
rung of a step stool
Reports injury occurred 1 week ago
Denies other injuries besides foot wound
Reports being barefoot at the time of
injury
Denies seeing a healthcare provider for
the injury until now
Asked about drainage from the foot
wound
Reports that the wound bled a little after
sustaining the injury
Reports seeing pus draining from wound
Reports noticing pus 2 days ago
Followed up on drainage Reports pus as white or yellow
Denies odor from the wound
Asked about home treatment of foot
wound
Reports wound care regimen of
bandaging
Reports cleaning wound twice a day
Reports applying bacitracin, neomycin
and polymyxin B (Neosporin)
Followed up on effectiveness of
ointment
Reports bacitracin, neomycin and
polymyxin B (Neosporin) was ineffective
Asked about other foot wound
symptoms
Reports swelling around foot wound
Reports swelling worsened in the past 2
days
Reports redness around the wound
Reports that the wound feels warm [Show Less]