Rachel Adler Alcohol Use Disorder shadow health Objective Data Collection
Objective Data Collection: 21 of 21 (100%)
- Correct
- Partially correct
- Incorrect
- Missed
Assessed Vitals
1 of 1 point
Temperature (1/5 point)
- Normothermic
- Hyperthermic
- Hypothermic
Blood Pressure (1/5 point)
- Normotensive
- Hypertensive
- Hypotensive
Heart Rate (1/5 point)
- Normal
- Tachycardic
- Bradycardic
Respiratory Rate (1/5 point)
- Normal
- Tachypnea
- Bradypnea
O2 Saturation (1/5 point)
- Normal
- Hypoxemia
- Rachel Adler Alcohol Use Disorder shadow health Objective Data Collection
Inspected Eyes
1 of 1 point
Pupillary Reaction (1/2 point)
- Normal
- Unequal
- Irregular
- Miosis
- Mydriasis
- Non-reactive to light
Accommodation (1/2 point)
- Normal constriction and dilation
- Unequal or no pupillary constriction
- Unequal or no pupillary dilation
Inspected Injury
1 of 1 point
Left Hand (1/4 point)
- Normal
- Swelling
- Redness
- Bruising
- Rash
Left Wrist (1/4 point)
- Normal
- Swelling
- Redness
- Bruising
- Rash
Right Hand (1/4 point)
- Normal
- Swelling
- Redness
- Bruising
- Rash
Right Wrist (1/4 point)
- Normal
- Swelling
- Redness
- Bruising
- Rash
Inspected Upper Extremities for Self-harm or Abuse
1 of 1 point
Observations (1/3 point)
- No visible evidence of self-harm or abuse
- Evidence of self-harm
- Evidence of abuse
Wounds Or Scars (1/3 point)
- No visible wounds or scars
- Wound visible
- Scar visible
Location Of Visible Abnormality (1/3 point)
- No visible abnormality
- Right upper arm
- Right lower arm
- Right wrist
- Right hand
- Left upper arm
- Left lower arm
- Left wrist
- Left hand
Auscultated Breath Sounds
1 of 1 point
Breath Sounds (1/2 point)
- Clear in all areas
- Diminished in some areas
- Absent in some areas
Adventitious Sounds (1/2 point)
- No adventitious sounds
- Wheezing
- Fine crackles
- Stridor
- Rhonchi
- Rales
Auscultated Heart Sounds
1 of 1 point
Heart Sounds (1/3 point)
- S1 and S2 audible
- S1, S2, and S3 audible
- S1, S2, and S4 audible
- S1, S2, S3, and S4 audible
Extra Heart Sounds (1/3 point)
- No extra sounds
- Gallops
- Murmur
- Friction rub
- Valve clicks
Rate And Rhythm (1/3 point)
- Regular rate and rhythm
- Arrhythmia
Palpated Radial Arteries
1 of 1 point
Right: Vibration (1/4 point)
- No thrill
- Thrill
Right: Amplitude (1/4 point)
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
Left: Vibration (1/4 point)
- No thrill
- Thrill
Left: Amplitude (1/4 point)
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
Tested Capillary Refill
1 of 1 point
Right Hand (1/2 point)
- Less than 2 seconds
- Greater than 2 seconds
Left Hand (1/2 point)
- Less than 2 seconds
- Greater than 2 seconds
Assessed General Appearance
1 of 1 point
Eye Contact (1/4 point)
- Direct eye contact
- Indirect or no eye contact
Posture (1/4 point)
- Upright posture without tension or rigidity
- Bent or hunched posture, tension, or rigidity
- Rachel Adler Alcohol Use Disorder shadow health Objective Data Collection
Clothing (1/4 point)
- Clean clothing, appropriate to age, fit, season and occasion
- Dirty, disheveled, or inappropriate to age, fit, season, or occasion
- Rachel Adler Alcohol Use Disorder shadow health Objective Data Collection
Grooming (1/4 point)
- Demonstrates an appropriate level of grooming
- Signs indicating lack of grooming or self-care
Assessed Attitude Toward Medical Staff
1 of 1 point
Attitude Toward Medical Staff (1/1 point)
- Generally open and cooperative
- Generally suspicious, guarded, or evasive
Assessed Speech
1 of 1 point
Rate (1/3 point)
- Demonstrates appropriate or expected rate of speech
- Excessively slow or rapid rate of speech
Volume (1/3 point)
- Demonstrates appropriate or expected speech volume
- Excessively loud or soft speech volume
Articulation (1/3 point)
- No appreciable issues with articulation
- Issues with articulation, slurring, or stutters
Assessed Mood and Affect
1 of 1 point
Mood (1/2 point)
- Stable mood with little or no fluctuation throughout the interview
- Frequent and appreciable mood changes throughout the interview
Affect (1/2 point)
- Full or balanced (normal)
- Expansive affect (excessively cheerful affect characterized by contagious laughter or smiling)
- Blunted or flat affect (little to no variation of expression regardless of conversation topic)
Assessed Thought Process
1 of 1 point
Thought Process (1/1 point)
- No presence of thought process disturbances
- Presence of rapid thinking, disorganized or illogical flow of thought, “word salad,” neologisms, echolalia, or clanging associations
Assessed Thought Content
1 of 1 point
Thought Content (1/2 point)
- No presence of thought content disturbances
- Presence of delusions, obsessive or intrusive thoughts, or suicidal or homicidal ideation
Perceptual Disturbances (1/2 point)
- No presence of perceptual disturbances
- Presence of auditory or visual hallucinations
Confirmed Orientation
1 of 1 point
To Person (1/4 point)
- Oriented to person
- Not oriented to person
To Place (1/4 point)
- Oriented to place
- Not oriented to place
To Time (1/4 point)
- Oriented to time
- Not oriented to time
To Situation (1/4 point)
- Oriented to situation
- Not oriented to situation
Assessed Serial Sevens
1 of 1 point
Serial Sevens (1/1 point)
- Able to complete the series
- Unable to complete the series
Assessed Abstract Thinking
1 of 1 point
Abstract Thinking (1/1 point)
- Demonstrates abstract thinking with similarities test
- Demonstrates concrete thinking with similarities test
Assessed Memory
1 of 1 point
Memory (1/1 point)
- Remote and immediate memory intact
- Remote or immediate memory not intact
Assessed Visuospatial Ability
1 of 1 point
Visuospatial Ability (1/1 point)
- Visuospatial ability intact for interlocking shapes test
- Visuospatial ability impaired with interlocking shapes test
Assessed Insight
1 of 1 point
Insight (1/1 point)
- Demonstrates full awareness of illness and willingness to seek treatment
- Demonstrates limited or no awareness of illness and/or is unwilling to seek treatment
Assessed Judgment
1 of 1 point
Judgment (1/1 point)
- Demonstrates good judgment
- Judgment poor or impaired judgment
- Rachel Adler Alcohol Use Disorder shadow health Objective Data Collection