Liam Fitzgerald Shadow Health Telehealth Follow-Up Sick Visit

Subjective Data Collection: 71 out of 75 (94.7%)

Table of Contents

Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

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Found:

Indicates an item that you found.

Available:

Indicates an item that is available to be found.

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.

Telehealth Protocol

Finding:

Asked the patient if they are in an appropriate environment for a visit.

Finding:

Confirms they are at a space where the visit can be conducted (Found).

Pro Tip: Telehealth visits conducted through video and audio tools require specific considerations to maintain standards of practice. Asking a patient about their ability to conduct the visit in a private space, addressing the confidentiality of the visit, and asking about any audio or visual accessibility issues are important steps for conducting a telehealth visit and maintaining standards of care.

Example Question:
Are you in a place where you can conduct a telehealth visit?

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Finding:

Asked if they can hear the provider.

Finding:

Confirms they are able to hear the provider (Found).

Example Question:
Can you hear me OK?

Finding:

Inform the patient this is a confidential protected visit.

Finding:

Acknowledges that they are aware that this is a confidential protected visit (Found).

Example Question:
Have you been informed that this is a confidential protected visit?

Episodic Heart Failure Questionnaire

Finding:

Asked how the patient is doing.

Finding:

Reports doing well (Found).

Pro Tip: For heart failure patients, it is essential to monitor any daily changes in a patient’s chronic condition to prevent the exacerbation of heart failure and promote the patient’s overall health. By asking a wide range of questions, you can determine if the patient is experiencing worsening heart failure, which may be indicated by chest pain, shortness of breath, cough, edema, as well as changes in weight or vitals. Additionally, scope of practice is important to keep in mind in order to determine if the patient’s worsening condition warrants a referral to their cardiologist or immediate hospitalization.

Example Question:
How are you doing?

Finding:

Asked about taking vital signs.

Finding:

Reports taking vitals daily (Found).

Example Question:
Have you been taking your vital signs daily?

Finding:

Reports taking vitals at the same time each day (Available).

Example Question:
Have you been taking your vital signs at the same time each day?

Finding:

Reports no problems with equipment (Available).

Example Question:
Have you had any issues with your equipment?

Finding:

Asked about respiratory symptoms.

Finding:

Denies cough (Available).

Example Question:
Do you have a cough?

Finding:

Denies wheezing (Available).

Example Question:
Do you have any respiratory symptoms?

Finding:

Denies shortness of breath or trouble breathing (Found).

Anxiety Assessment and Treatment in a Middle-Aged Caucasian Male

Example Question:
Do you have shortness of breath?

Finding:

Denies any trouble breathing with activity (Available).

Pro Tip: For heart failure patients, it is essential to monitor any daily changes in a patient’s chronic condition to prevent the exacerbation of

heart failure and promote the patient’s overall health. By asking a wide range of questions, you can determine if the patient is experiencing worsening heart failure, which may be indicated by chest pain, shortness of breath, cough, edema, as well as changes in weight or vitals. Additionally, scope of practice is important to keep in mind in order to determine if the patient’s worsening condition warrants a referral to their cardiologist or immediate hospitalization.

Example Question:
Do you have trouble breathing with activity?

Finding:

Asked about cardiovascular symptoms.

Finding:

Denies chest pain (Found).

Example Question:
Do you have any chest pain?

Finding:

Denies palpitations (Found).

Example Question:
Do you have any palpitations?

Finding:

Reports swelling (Found).

Example Question:
Do you have any swelling?

Finding:

Asked about the location of swelling.

Finding:

Reports swelling in feet and ankles (Found).

Example Question:
Where is your swelling located?

Finding:

Asked about the onset of swelling.

Finding:

Reports noticing swelling within the last 24 hours (Available).

Example Question:
When did the swelling start?

Finding:

Asked about the character of swelling.

Finding:

Reports feet and ankles are puffy (Available).

Example Question:
Can you describe the swelling?

Finding:

Reports socks left an indentation on the ankle (Available).

Example Question:
Can you describe the swelling?

Finding:

Asked about integumentary symptoms.

Finding:

Denies itchy, dry skin (Found).

Example Question:
Do you have any integumentary symptoms?

Finding:

Asked about taking daily weight logs.

Finding:

Reports taking daily weight logs (Available).

Example Question:
Have you been taking daily weight logs?

Finding:

Reports weighing self at the same time every day (Available).

Example Question:
Have you been weighing yourself at the same time every day?

Finding:

Reports wearing the same type of clothing to weigh self every day (Available).

Example Question:
Are you wearing the same clothes to weigh yourself every day?

Finding:

Asked about changes to weight.

Finding:

Reports weight gain (Found).

Example Question:
Have there been any recent changes to your weight?

Finding:

Reports gaining 4-5 lbs (Found).

Example Question:
Have there been any recent changes to your weight?

Finding:

Asked about the timing of weight gain.

Finding:

Reports noticing weight gain within the past 24 hours (Available).

Example Question:
When did you notice the weight gain?

Finding:

Asked about pain status.

Finding:

Denies pain (Available).

Example Question:
Do you have any pain?

Finding:

Asked about typical diet.

Finding:

Reports limiting sodium intake (Found).

Example Question:
Do you limit your sodium intake?

Finding:

Reports typical breakfast as oatmeal with fruit (Found).

Example Question:
What do you typically eat for breakfast?

Finding:

Reports typical lunch as salads, homemade soups, pasta with grilled chicken and vegetables (Found).

Example Question:
What do you typically eat for lunch?

Finding:

Reports typical dinner as grilled chicken or fish with roasted vegetables, brown rice (Found).

Example Question:
What do you typically eat for dinner?

Finding:

Reports typical snack as no-salt almond butter with apple, no-salt air-popped popcorn (Found).

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Liam Fitzgerald Shadow Health Telehealth Follow-Up Sick Visit