Shadow Health Interview Guidelines

Shadow Health Interview Guidelines

Shadow Health Interview Guidelines

You will be evaluated on your ability to use the patient’s context to construct a health interview

• Ask questions about each relevant topic of a pt interview to collect pt data
• Listen to the patient’s responses for cues that prompt
• Follow-up questions
• Empathy
• Patient education
• Document patient data in the HER

Multiple essential questions for:

• Chief Complaint
• History of Present Illness
• Medical History:
• Medication
• Allergies
• Immunizations
• Diabetes
• Asthma
• Hypertension
• Gynecological and Sexual History
• Social History:
• Daily Life
• Diet and Nutrition
• Substance Use
• Review of Systems
• Family History:
• 3 Generations
• Inherited Risk Factors

Know all of your qualifying questions for any symptom that may be reported:  • Onset  • Location • Duration • Characteristics • Aggravating/alleviating factors  • Related symptoms • Treatments tried

SOAP note:

Subjective: The “s”, or subjective data portion of your SOAP note should include your chief complaint, HPI, and any relevant medical, family, or history pertaining to the patient’s chief complaint as well as a focused review of systems. This is the information that the patient reports directly to you. Shadow Health Interview Guidelines.

(The patient is a 70 year old female complaining of abdominal pain and indigestion.  The dull, constant pain is located in the upper right quadrant of her abdomen. It started four days ago and is occasionally also in her right shoulder blade.  Nausea accompanies the pain.   Eating worsens the pain, making her feel excess gas and bloating.  Rolaids normally lessens the pain, but did not improve her pain in the last incident. One a scale of 10, she rates the pain as an 8. PMH – no significant PMH Family Hx – Her brother had his gallbladder removed 2 years ago. Mother died of alzheimer’s, father of heart attack. Social Hx –  Married, currently retired after raising her family and working as a homemaker her whole life. She walks 3 times a week for 30 minutes. Rarely drinks and doesn’t smoke. ROS – General decrease in appetite. Fear of eating.  Skin rash on feet.)

 

Objective: The “o” or objective data portion of your SOAP note should include your vital signs, clinical exam, and any blood work or radiology exams that have been done recently. In this portion you want to give a clear clinical picture of what is going on with the patient. This portion of a S.O.A.P note consists of what you, the clinician can observes. It can be measurable.

(Vital Signs – BP 125/85, P 70 bpm, R 16 breaths, T 99.1 ?F The patient is friendly and well groomed. She is not in any obvious distress.  HEENT – pupils round reactive to light. No scleroicteris.  Moist Mucous membranes.  No lymphadenopathy, no thyromegaly, bruits, neck supple.   Respiratory – Lungs clear on auscultation.  Resonant to percussion. Cardiac – regular rate and rhythm. No murmurs or gallops Abdominal – No surgical scars, no distention. Normal active bowel sounds in all four quadrants. No bruits heard in abdominal aorta, renal arteries, or iliac arteries.  Discomfort was felt on light and deep palpation of the right upper quadrant. Liver and spleen are not enlarged.  She had no rebound tenderness or guarding. Breast and pelvic exams done by previous primary care physician. Extremities/musculoskeletal – 2+ radial and dorsalis pulses no clubbing or cyanosis or edema. Full range of motion in her shoulders, elbows, hands, hips, knees and ankles without pain tenderness or swelling.  No scapular tenderness.  Neuro – Cranial Nerves 2 – 12 intact. Strength 5/5 bilateral upper and lower extremities. Deep tendon reflexes 2+ throughout. Romberg normal, gait normal.) Shadow Health Interview Guidelines.

 

Assessment: In the “a”, or assessment portion, you are going to synthesize the subjective and objective data into a list of prioritized differential diagnosis. The likely diagnosis should be included in this section of the note. The assessment may also include information on various diagnostic tests that may be ordered, such as x-rays, blood work and referrals to other specialist.

• abdominal pain – presentation suggestive of gallstone disease. Less likely possibilities include hepatitis, gastritis, peptic ulcer disease, and atypical ischemic heart disease.)

Plan: In the “p”, or plan section of your SOAP note, you are going to discuss how you would like to treat your patient. It should include what type of treatments will be given, such as medication, therapies, and surgeries. It may also list long-term treatment plans and recommended changes to lifestyle, as well as short and long term goals for the patient. It should also detail what kind of follow up is necessary

(Workup will include a sonogram of the RUQ and complete blood count and liver chemistries, and an EKG. We will have the patient follow up with results.)

 

Example of self reflection

I asked Mrs. Smith about her health history and tried to find more in- formation about her low back pain, cough, and frequent urinary tract infections. OLDCARTS helped guide me through the 7 dimensions of her complaints. I assumed that if I went through OLDCARTS I would capture all of the information, and it seems that it really helped me get a very clear picture of the problem. I asked about her self-care related to her frequent urinary tract infections to get a good idea of what education and care she would need to prevent them. I should have addressed Mrs. Smith’s nutrition plan. This would help her manage her obesity, which is probably contributing to her low back pain. I should have asked 

Mrs. Smith about the possibility of quitting smoking and about whether she had ever tried to quit (Stead et al., 2008). 

When I reviewed my transcript,it became apparent that I kept it purely medical and rarely asked any social or cultural questions. I used Jarvis to ask the subjective questions but didn’t think much about finding much else out. This has been really good for me to remember to think of my patients as people with families and lives as well as medical problems.Citation: Stead, L. F., Bergson, G., & Lancaster, T. (2008). Physician advice for smoking cessation. Co- chrane Database Syst Rev, 2 (2). 

Shadow Health Interview Guidelines

ORDER NOW FOR A CUSTOM-WRITTEN, PLAGIARISM-FREE PAPER WITH ALL INSTRUCTIONS FOLLOWED