Chief Complaint

Finding:

Established chief complaint and reason for admittance

Finding:

Reports car accident

(Found)

Pro Tip: A patient's chief complaint establishes any illnesses or concerns they are presenting.

Asking about the chief complaint will allow the patient to voice any concerns or symptoms the

patient may have.

Example Question:

Why were you admitted?

Finding:

Reports injury

(Found)

Pro Tip: A patient's chief complaint establishes any illnesses or concerns they are presenting.

Asking about the chief complaint will allow the patient to voice any concerns or symptoms the

patient may have.

Example Question:

What caused your injury?

Finding:

Reports passive suicidal ideation

(Found)

Pro Tip: A patient's chief complaint establishes any illnesses or concerns they are presenting.

Asking about the chief complaint will allow the patient to voice any concerns or symptoms the

patient may have.

Example Question:

What brings you in today?

History of Present Illness

Finding:

Followed up on details of car accident

Finding:

Reports loss of consciousness

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information

relevant to the history of their present illness. Details of their current complaint will help you

follow-up on any present conditions or symptoms, such as the location of their pain or the

amount of pain they may be experiencing.

Example Question:

Did you lose consciousness during the car accident?

Finding:

Reports being unsure of how the accident happened

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information

relevant to the history of their present illness. Details of their current complaint will help you

follow-up on any present conditions or symptoms, such as the location of their pain or the

amount of pain they may be experiencing.

Example Question:

Do you know what caused the car accident?

Finding:

Reports wearing seatbelt

(Available)

Pro Tip: Asking a patient about the length of their current health issues solicits information

relevant to the history of their present illness. Details of their current complaint will help you

follow-up on any present conditions or symptoms, such as the location of their pain or the

amount of pain they may be experiencing.

Example Question:

Were you wearing a seatbelt?

Finding:

Reports being the driver - no other passengers in car

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information

relevant to the history of their present illness. Details of their current complaint will help you

follow-up on any present conditions or symptoms, such as the location of their pain or the

amount of pain they may be experiencing.

Example Question:

Who was driving before the car accident?

Finding:

Reports was told she would get a ticket for DUI

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information

relevant to the history of their present illness. Details of their current complaint will help you

follow-up on any present conditions or symptoms, such as the location of their pain or the

amount of pain they may be experiencing.

Example Question:

What caused the car accident?

Finding:

Followed up on alcohol use just prior to car accident

Finding:

Reports drinking before accident

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information

relevant to the history of their present illness. Details of their current complaint will help you

follow-up on any present conditions or symptoms, such as the location of their pain or the

amount of pain they may be experiencing.

Example Question:

Were you drinking before the accident?

Finding:

Reports being unsure of how many drinks - "at least 5"

(Available)

Pro Tip: Asking a patient about the length of their current health issues solicits information

relevant to the history of their present illness. Details of their current complaint will help you

follow-up on any present conditions or symptoms, such as the location of their pain or the

amount of pain they may be experiencing.

Example Question:

How much did you drink before the accident?

Finding:

Reports was drinking with friends at a party

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information

relevant to the history of their present illness. Details of their current complaint will help you

follow-up on any present conditions or symptoms, such as the location of their pain or the

amount of pain they may be experiencing.

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

(Available)

Pro Tip: Asking a patient about the length of their current health issues solicits information

relevant to the history of their present illness. Details of their current complaint will help you

follow-up on any present conditions or symptoms, such as the location of their pain or the

amount of pain they may be experiencing.

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

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information

relevant to the history of their present illness. Details of their current complaint will help you

follow-up on any present conditions or symptoms, such as the location of their pain or the

amount of pain they may be experiencing.

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

(Available)

Pro Tip: Asking a patient about the length of their current health issues solicits information

relevant to the history of their present illness. Details of their current complaint will help you

follow-up on any present conditions or symptoms, such as the location of their pain or the

amount of pain they may be experiencing.

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

(Available)

Pro Tip: Asking a patient about the length of their current health issues solicits information

relevant to the history of their present illness. Details of their current complaint will help you

follow-up on any present conditions or symptoms, such as the location of their pain or the

amount of pain they may be experiencing.

Example Question:

Did you drive under the influence in order to hurt yourself?