Shadow Health Focused Exam: Rachel Adler (Subjective Interview and SBAR)

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Shadow Health Focused Exam: Rachel Adler – ETOH Chief Complaint Finding: Established chief complaint and reason for admittance Finding: Reports car accident Example Question: Why were you adm... itted? Finding: Reports injury Example Question: What caused your injury? Finding: Reports passive suicidal ideation Example Question: What brings you in today? History of Present Illness Finding: Followed up on details of car accident Finding: Example Question: Did you lose consciousness during the car accident? Finding: Reports being unsure of how the accident happened Example Question: Do you know what caused the car accident? Finding: Reports wearing seatbelt Example Question: Were you wearing a seatbelt? Finding: Reports being the driver - no other passengers in car Example Question: Who was driving before the car accident? Finding: Reports was told she would get a ticket for DUI Example Question: What caused the car accident? Finding: Followed up on alcohol use just prior to car accident Finding: Reports drinking before accident Example Question: Were you drinking before the accident? Finding: Reports being unsure of how many drinks - "at least 5" Example Question: How much did you drink before the accident? Finding: Reports was drinking with friends at a party Example Question: Who were you drinking with? Finding: Reports left party to drive home because she was mad at her girlfriend and could not take any more Example Question: Why did you leave the party? Finding: Asked about driving impaired Finding: Reports knew she was driving under the influence but did not care Example Question: Did you know you were too drunk to drive? Finding: Reports have driven in past after drinking, but this time she did not care if she injured herself Example Question: Did you care that you were driving under the influence? Finding: Followed up on impaired driving - risk for self harm Finding: Reports has had enough of life and did not care if she got hurt/died Example Question: Did you drive under the influence in order to hurt yourself? Finding: Reports had not thought about self harm before accident Example Question: Have you ever wanted to hurt yourself before the accident? [Show More]

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