Fatima Khan Shadow Health Documentation

Vitals

Vitals	0800	1000
Temp (<38° C)	36.7° C	36.5° C
BP (<120/80)	124/80	122/78
HR (60-100)	70	68
RR (12-20)	18	18
O2 Sat (>94%)	99%	99%

My Provider Notes

Student Documentation	Model Documentation
Subjective Ms Fatina Khan is a patient who is preparing for her surgery. She report to .. or fatigue	Ms. Fatima Khan is a 44 year old female that is admitted for acute cholelithiasis and is scheduled for a laparoscopic cholecystectomy today. Upon initial assessment, she is oriented to person only and states that she is feeling confused. She … and shaky. She also reports a rapid heartbeat. She denies any gastrointestinal problems. The patient states…Fatima Khan Shadow Health Documentation

Student Documentation

Model Documentation

Subjective

Ms Fatina Khan is a patient who is preparing for her surgery. She report to .. or fatigue

Ms. Fatima Khan is a 44 year old female that is admitted for acute cholelithiasis and is scheduled for a laparoscopic cholecystectomy today. Upon initial assessment, she is oriented to person only and states that she is feeling confused. She … and shaky. She also reports a rapid heartbeat. She denies any gastrointestinal problems. The patient states…Fatima Khan Shadow Health Documentation

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During the patient interview, there are a number of opportunities to provide patient education and empathy. The opportunities listed below are those identified by nursing experts to be of particular importance to this patient. A Model Statement is provided as an example of an appropriate response to each opportunity.

Opportunities marked as Not Encountered are opportunities that were not elicited in the interview
Opportunities marked as Not Followed Up are missed opportunities that were present in the interview, but where no statements were made
Opportunities marked as Followed Up were followed up by students, and include the dialogue between student and patient

1 Symptoms

Followed Up

	Description: Ms. Khan expresses that she feels ill and describes her symptoms as confusion, sweatiness, and rapid heartbeat.
	Do you have any heart problem?	Question 05:26 PM EDT
	Not usually, but . . . it’s beating rapidly right now.
	I am sorry to hear that	Question 05:26 PM EDT
	I can hear you fine. Fatima Khan Shadow Health Documentation
	For how long has your heart been beating rapidly?	Question 05:29 PM EDT
	I don’t know when it began.
	Do you feel nauseated?	Question 05:29 PM EDT
	I’m not nauseated. I just feel really strange.
	I am sorry about that. We shall establish the problem and make you feel better	Empathize 05:30 PM EDT
	Thank you.
	Model Statement: “I’m sorry to hear that you are feeling like this. Your rapid heartbeat, sweatiness, and confusion may be symptoms of a change in your condition. I’m going to do everything I can to get you feeling better.”

2 Identifying Cause of Symptoms

Followed Up

	Description: Ms. Khan reports recently administering a bolus of insulin despite a normal blood glucose reading.
	Have you taken any medications? (Clarified to: What medicines have you taken lately?)	Question 05:30 PM EDT
	I just took it Fatima Khan Shadow Health Documentation. (Clarified to: what medicines I have taken lately)
	Do you know why you were given the medicine (Clarified to: Do you know why you are here today?)	Question 05:31 PM EDT
	I . . . um . . . well, I’m not sure why I’m here. (Clarified to: if I know why I am here)
	Which medication did you take	Question 05:32 PM EDT
	I just took it.
	do you know the name of the medicine you just took (Clarified to: What medications do you take?)	Question 05:33 PM EDT
	Ah . . . I’m taking Sim . . . Sima . . . vast . . . ah . . . for my heart, and um . . . insulin. Um . . . (Clarified to: what medications I am taking)
	When was your last dose of insulin	Question 05:33 PM EDT
	Um . . . I just gave myself insulin.
	Do you have any pain	Question 05:37 PM EDT
	No . . . it isn’t a pain.
	Do you have any special needs (Clarified to: Do you have any religious preferences while you are here?)	Question 05:38 PM EDT
	I am a Muslim, so please only provide halal foods and medicines. I would also prefer you try to only touch me with your right hand. (Clarified to: if I have religious preferences while I am here) Fatima Khan Shadow Health Documentation
	Thats okay, we will try our best to meet your needs and preferences	Empathize 05:39 PM EDT
	Thank you very much.
	Model Statement: “Based on your symptoms and what you’ve told me about taking an insulin bolus recently, it’s possible you may have administered too much insulin. It’s important to use your insulin only when your blood glucose reading indicates the need for a bolus. When you take more insulin than is required, this can make you feel ill, meaning you may feel symptoms such as confusion, sweatiness, and a rapid heartbeat.”

Fatima Khan Shadow Health Documentation