Shadow Health Assignments
Alcohol Use Disorder Rachel Adler shadow health Documentation
Documentation / Electronic Health Record
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Nursing Admitting Note Student Documentation Model Documentation Chief Complaint
Injured wrist due to a car accident caused by drinking alcohol.
Ms. Adler hurt her right wrist in a car crash caused by drinking alcohol. She’s at risk of self-harm and has talked about feeling like she might want to end her life. History of Present Illness
Rachel Adler is a 20-year-old White woman who has used alcohol and has anxiety. Law enforcement brought her after a car accident where she was driving drunk and hurt her wrist.
Rachel Adler, a 20-year-old White woman, has a history of using alcohol and dealing with anxiety. She came to the ER with law enforcement after a car accident. She was driving under the influence of alcohol and hurt her right wrist. ER assessment found a sprained right wrist, and her blood alcohol level was 0.2% (higher than the legal limit for those under 21) at the scene. She doesn’t remember what happened but knows she got a DUI ticket. She said her pain level was 8/10 when she got to the ER. Her pain got better after taking ibuprofen. She didn’t feel nauseous or vomit. She was admitted to the adult mental health unit because she’s a risk for self-harm. Alcohol Use Disorder Rachel Adler Shadow Health Documentation Allergies
Allergic to peanuts, no other known allergies.
She’s allergic to peanuts, which makes her mouth and throat itch. She doesn’t have any other known allergies. Past Medical History
No known medical problems.
Alcohol Use Disorder Rachel Adler Shadow Health Documentation
She hasn’t had any medical problems. She doesn’t use recreational drugs or tobacco. Past Surgical History
No past surgeries.
She hasn’t had any surgeries before. Medication History
Ibuprofen Ortho Tri Cyclen Lo, takes one tablet daily.
She takes Ortho Tri Cyclen Lo, one tablet by mouth, every day at 8 AM. She also takes ibuprofen occasionally for menstrual cramps. Family History
Father: No health issues Mother: has an anxiety disorder Maternal grandfather: had alcoholism.
Her mother has an anxiety disorder. Her father is healthy. Her maternal grandfather had issues with alcoholism. Social History
She’s a junior college student, single, not sexually active. She doesn’t use tobacco or illegal drugs but drinks alcohol at least three times a week.
She’s a junior college student and single, but she’s sexually active. She practices safe sex. She doesn’t use tobacco or nicotine. She doesn’t do drugs, and she drinks alcohol at least three times a week. Thought Content
She’s thought about not wanting to live.
Ms. Adler has had thoughts about not wanting to live and has said she doesn’t care if she lives or dies. She hasn’t talked about actively wanting to end her life or making plans to do so. She’s never tried to commit suicide or planned to. She’s feeling stressed because of school and her relationship with her mother. She’s very upset about her DUI and how she ended up in the ER. Perceptual Disturbances
She doesn’t have strange thoughts or behaviors.
Ms. Adler doesn’t have any signs of strange thoughts or behaviors during the exam. She doesn’t have hallucinations or false sensory experiences. Alcohol Use Disorder Rachel Adler Shadow Health Documentation
Alcohol Use Disorder Rachel Adler shadow health Documentation
Documentation / Electronic Health Record
Nursing Admitting Note
| Student Documentation | Model Documentation |
|---|---|
Chief ComplaintSprained wrist due to a car accident caused by drinking under the influence of alcohol. |
Ms. Adler has a sprained (R) wrist due to an MVA caused by impaired driving. She is a self-harm risk and expressed passive suicidal ideation. |
History of Present IllnessRachel Adler isa 20-year old White female with a history of alcohol use and anxiety. She was brought by law enforcement after a moving vehicle accident in which she was driving under the influence of alcohol and injured her wrist. |
Rachel Adler is a 20-year-old White woman with a history of alcohol use and anxiety. She was brought to the ER last night by law enforcement after a MVA in which she was noted to be under the influence of alcohol and had an injured her (R) wrist. Assessment in the ER confirmed a sprain of the (R) wrist, and an alcohol level of 0.2% (over the legal limit in the state for individuals under the age of 21) was determined at the scene. Ms. Adler stated she did not know what happened, but was told she received a ticket for DUI. Reported pain level upon arrival to the ER to be 8/10. Pain relief noted when ibuprofen administered. Ms. Adler denies any nausea, vomiting. Admitted to adult mental health unit based on positive assessment for self harm. Alcohol Use Disorder Rachel Adler shadow health Documentation |
AllergiesPeanut allergy NKDA |
Peanuts, reaction is itchy mouth and throat NKDA |
Past Medical HistoryNo medical issues Alcohol Use Disorder Rachel Adler shadow health Documentation |
No medical issues Denies use of recreational drugs, denies tobacco use |
Past Surgical HistoryNo past surgeries. |
No past surgical procedures |
Medication HistoryIbuprofen Ortho Tri Cyclen Lo, 1 tablet daily |
Ortho Tri Cyclen Lo, 1 tablet, P.O., daily at 0800 “Click pack” Occasional ibuprofen for menstrual cramps |
Family HistoryFather: No health issues Mother: anxiety disorder Maternal grandfather: alcoholism |
Mother has anxiety disorder Father has no major medical issues Maternal grandfather had a history of alcoholism |
Social HistoryJunior college student. Single, not sexually active. Denies tobacco and illicit drugs use Uses alcohol at least 3 times a week. |
College student – Junior. Single – sexually active, not in relationship at this time. Practices safe sex. Tobacco: denies present use of tobacco and nicotine use. Alcohol/Illicit Drug Use: denies any illicit drug use. Uses alcohol at Alcohol Use Disorder Rachel Adler shadow health Documentation |
Thought ContentPassive suicidal ideation |
Ms. Adler displays passive suicidal ideation and expresses that she does not care if she lives or dies. Ms. Adler does not express any active suicidal ideation or plans for ending her life. She says she has never attempted suicide or planned a suicide attempt. Ms. Adler seems to be under stress from school and her relationship with her mother. She is deeply distraught over her DUI and the circumstances that brought her to the ER. |
Perceptual DisturbancesNo delusions or abnormal tendencies |
Ms. Adler displays no evidence of delusions or observable abnormal tendencies during the exam. There is no evidence of hallucinations or false sensory perceptions. Alcohol Use Disorder Rachel Adler shadow health Documentation Dont wait until the last minute.Provide your requirements and let our native nursing writers deliver your assignments ASAP. |