Subjective Data (page 1-27)
Education/Empathy (pages 27-28)
SBAR (page 28-29)
Chief Complaint
• Finding:
Asked about chief complaint
• Finding:
Reports being brought in by police
Why are you in the emergency department tonight?
History of Present Illness
• Finding:
Followed up on incident
• Finding:
Reports looking into cars for government agents chasing him
What were you doing when the police found you?
• Finding:
Reports having been in a grocery store parking lot
Where were you when the police found you?
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• Finding:
Reports knowing the police stopped him for running around and looking in cars
Do you know why the police brought you in?
• Finding:
Denies having hurt himself or others
Were you hurting anyone?
• Finding:
Denies having done anything illegal
Were you doing anything illegal?
• Finding:
Followed up on government agents
• Finding:
Reports government is trying to imprison him for being enlightened
Why are the government agents following you?
• Finding:
Reports government sees his enlightenment as a threat to their secrets
Why are the government agents following you?
• Finding:
Asked about anxiety or paranoia
• Finding:
Denies anxiety or paranoia
Are you feeling anxious or paranoid?
• Finding:
Reports high awareness of government agents chasing him
What is making you anxious?
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Downloaded by Anna Maina (annamurugijoe@gmail.com)
• Finding:
Asked about hallucinations
• Finding:
Denies hallucinations
Do you ever see things others can't?
• Finding:
Asked about most recent substance use
• Finding:
Reports last substance use was about four days ago
When was the last time you used substances?
• Finding:
Reports last substance use was cocaine
What substance did you use four days ago?
• Finding:
Asked about recent sleep history
• Finding:
Reports not having slept for four days
When was the last time you slept?
• Finding:
Asked about current energy levels
• Finding:
Reports current extremely high energy
How would you describe your energy right now?
• Finding:
Asked about current mood
• Finding:
Reports current euphoria
What kind of mood are you in?
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Downloaded by Anna Maina (annamurugijoe@gmail.com)
• Finding:
Asked about onset of energy and mood
• Finding:
Reports high energy began a week ago
How long have you been feeling this energetic?
• Finding:
Reports euphoria began a week ago
How long have you been feeling euphoric?
Past Medical History
• Finding:
Asked about existing health conditions
• Finding:
Reports being diagnosed with depression
What existing health conditions do you have?
• Finding:
Asked about typical moods
• Finding:
Reports periods of euphoria
Do you have periods of feeling really good?
• Finding:
Reports periods of depression
Do you have periods of feeling really bad?
• Finding:
Asked about typical energy levels
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