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Patient Status
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.
Finding:
Asked about patient's status
Finding:
Reports feeling alright
(Found)
Pro Tip: At the start of your conversation, check in with a patient about their current feelings so you can immediately build rapport through empathetic communication.
Example Question:
How are you feeling?
Finding:
Asked about patient's needs
Finding:
Denies needing anything
(Found)
Pro Tip: At the start of your conversation, check in with a patient about their current feelings so you can immediately build rapport through empathetic communication.
Example Question:
Do you need anything?
Finding:
Asked about feelings towards pregnancy or delivery
Finding:
Reports nervousness
(Found)
Pro Tip: At the start of your conversation, check in with a patient about their current feelings so you can immediately build rapport through empathetic communication.
Example Question:
How are you feeling about giving birth?
Finding:
Reports excitement over being a mom
(Available)
Finding:
Followed up on pain
Finding:
Reports feeling contractions low in her groin
(Found)
Pro Tip: Ask a patient about their comfort and any symptoms, so that you can determine the nature of their condition and where follow-up is needed.
Example Question:
Where is the pain from your contractions?
Finding:
Reports 6/10 pain during contractions
(Found)
Pro Tip: Ask a patient about their comfort and any symptoms, so that you can determine the nature of their condition and where follow-up is needed.
Example Question:
How would you rate the pain during contractions?
Finding:
Asked about relieving factors
Finding:
Reports walking helped alleviate pain
(Found)
Pro Tip: Ask a patient about their comfort and any symptoms, so that you can determine the nature of their condition and where follow-up is needed.
Example Question:
Does anything help your pain?
Finding:
Reports walking stopped being effective for pain relief 15 minutes prior
(Found)
Pro Tip: Ask a patient about their comfort and any symptoms, so that you can determine the nature of their condition and where follow-up is needed.
Example Question:
Does walking still help your pain?
Finding:
Asked about current position
Finding:
Reports current position is acceptable
(Found)
Pro Tip: Ask a patient about their comfort and any symptoms, so that you can determine the nature of their condition and where follow-up is needed.
Example Question:
How is the position you're in?
Reports contractions began 5 hours ago
(Found)
Pro Tip: Ask a patient about their comfort and any symptoms, so that you can determine the nature of their condition and where follow-up is needed.
Example Question:
When did the contractions begin?
Finding:
Reports not being sure how long contractions last
(Found)
Pro Tip: Ask a patient about their comfort and any symptoms, so that you can determine the nature of their condition and where follow-up is needed.
Example Question:
How long do the contractions last?
Finding:
Asked how long she has been in labor
Finding:
Reports labor started 5 hours prior
(Found)
Pro Tip: Ask a patient about their comfort and any symptoms, so that you can determine the nature of their condition and where follow-up is needed.
Example Question:
How long have you been in labor?
Finding:
Asked if water has broken
Finding:
Reports concern that water has not broken
(Found)
Pro Tip: Ask a patient about their comfort and any symptoms, so that you can determine the nature of their condition and where follow-up is needed.
Example Question:
Has your water broken?
Finding:
Asked about pregnancy timeline
Finding:
Reports being 39 weeks into pregnancy
(Found)
Pro Tip: Ask a patient about their comfort and any symptoms, so that you can determine the nature of their condition and where follow-up is needed.
Example Question:
How far along are you?
Finding:
Reports due date was projected for 5 days from now
Past Medical History
Pro Tip: Asking a patient about their health and health maintenance throughout their pregnancy can inform you of their readiness for delivery and any problems to look out for.
Example Question:
Why did your prenatal visits start late?
Finding:
Reports waiting until after older sister's wedding to disclose pregnancy
(Found)
Pro Tip: Asking a patient about their health and health maintenance throughout their pregnancy can inform you of their readiness for delivery and any problems to look out for.
Example Question:
Why did your prenatal visits start late?
Finding:
Asked about pregnancy complications
Finding:
Denies complications
(Found)
Pro Tip: Asking a patient about their health and health maintenance throughout their pregnancy can inform you of their readiness for delivery and any problems to look out for.
Example Question:
Have you had any complications with your pregnancy?
Finding:
Asked about preexisting conditions
Finding:
Denies preexisting conditions
(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 medical conditions?
Finding:
Asked about allergies
Finding:
Denies 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 allergies?
Finding:
Reports more family members will arrive soon
(Available)
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 all of these diverse questions to understand how a patient's behaviors are affecting their health.
Example Question:
Do you have more family coming?
Finding:
Asked about substance use
Finding:
Reports drinking once before she knew she was pregnant
(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 all of these diverse questions to understand how a patient's behaviors are affecting their health.
Example Question:
Have you drank alcohol while pregnant?
Finding:
Denies tobacco use
(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 all of these diverse questions to understand how a patient's behaviors are affecting their health.
Example Question:
Have you used tobacco while pregnant?
Finding:
Asked about education
Finding:
Reports recently graduating from high school
(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 all of these diverse questions to understand how a patient's behaviors are affecting their health.
Example Question:
What education have you received?
Finding:
Reports planning to start online college classes soon
(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 all of these diverse questions to understand how a patient's behaviors are affecting their health.
Example Question:
Do you have plans to go to college?
Finding:
Review of Systems
Asked about home medications
Finding:
Reports taking 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 different prescription affect symptoms differently.
Example Question:
Do you take any medications?
Finding:
Asked about review of gastrointestinal system
Finding:
Reports last bowel movement was early in labor
(Available)
Pro Tip: Asking a patient about any symptoms occurring, system by bodily system, can help you ask about a patient's illness, which may affect some areas more than others.
Example Question:
Have you had a bowel movement since labor began?
Finding:
Finding:
Denies cardiovascular symptoms Denies hemorrhoids
(Found)
Pro Tip: Asking a patient about any symptoms occurring, system by bodily system, can help you ask about a patient's illness, which may affect some areas more than others.
Example Question:
Have you gotten hemorrhoids?
Finding:
Asked about review of urinary system
Finding:
Denies needing to urinate
(Available)
Pro Tip: Asking a patient about any symptoms occurring, system by bodily system, can help you ask about a patient's illness, which may affect some areas more than others.
Example Question:
Do you need to urinate currently?
Finding:
Asked about review of cardiovascular system
Assessed Labs 1 of 1 point Temperature (1/5 point)
- Normothermic
- Hyperthermic
- Hypothermic Heart Rate (1/5 point)
- Normal
- Tachycardic
- Bradycardic Respiratory Rate (1/5 point)
- Normal
- Tachypnea
- Bradypnea O2 Saturation (1/5 point)
- Normal
- Hypoxemia Blood Pressure (1/5 point)
- Normotensive
- Hypertensive
- Hypotensive Blood Type (1/5 point)
- O+
- O-
- A+
- A-
- B+
- B-
- AB+
- AB- Std Test (1/5 point) Assessed Vitals 1 of 1 point
Assessed IV Site 1 of 1 point Inspected Abdomen 1 of 1 point
Test does not indicate presence of syphilis or HIV
- Test indicates presence of syphilis but not HIV
- Test indicates presence of HIV but not syphilis
- Test indicates presence of HIV and syphilis Drug Screening (1/5 point)
- Negative for substances
- Positive for substances Complete Blood Count (Cbc) (1/5 point)
- No abnormal levels present
- Abnormal levels present Group B Strep Test (See Prenatal Review) (1/5 point)
- Negative for Group B Strep
- Positive for Group B Strep Insertion Site (1/2 point)
- No visible abnormal signs
- Erythema
- Infiltration Dressing (1/2 point)
- Dry and intact
- Wet dressing Symmetry (1/2 point)
- Symmetric
- Asymmetric Appearance (1/2 point)
- No visible abnormalities
- Rash
- Bulging around umbilicus
- Distension
