Shadow Health Assignments
Shadow Health Tina Jones Mental Health Documentation
Subjective
HPI: Ms. Jones came to the clinic because she’s having trouble sleeping. This started a month ago. She says her sleep isn’t deep and she’s awake around 8:00am. She usually gets 4 or 5 hours of sleep per night. She has a regular schedule on weekdays and weekends. She doesn’t use any medicine to sleep. She avoids screens before bed and doesn’t have caffeine after 4pm. She has felt stressed lately due to exams and finding a job after graduation. She has support from friends, family, and her church. She deals with stress by staying organized and likes reading and watching TV for about 1-2 hours daily. She has some alcohol occasionally and has used marijuana before, but not now. She drinks diet cola every day. She denies using tobacco and other drugs. She has been feeling a bit off lately and has more anxiety due to exams and job search. She’s never been diagnosed with depression but feels helpless and her work and school performance is suffering. She doesn’t have tension or memory loss and has never attempted suicide.
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Assessment
Sleep problems caused by anxiety
Plan
• She should keep track of her sleep and anxiety symptoms and bring the record to her next visit.
• Reduce caffeine and drink more water and fluids.
• Learn about xxx.
• Talk about the importance of regular sleep, good sleep habits, like not having caffeine after 2pm, drinking less before bed, avoiding screens after 8pm, and getting up if she wakes up at night.
• Learn about xxx and medications that can help with sleep (like diphenhydramine and Tylenol PM).
• Understand when to seek help urgently, like if she feels like hurting herself or hopeless.
• Come back for another appointment in 2-4 weeks to check how things are going.
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