Zachary LaFontaine Infant Well Visit Shadow health Subjective Data Collection

Zachary LaFontaine Infant Well Visit Shadow health Subjective Data Collection
Subjective Data Collection: 17 of 17 (100.0%)
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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
Found:
Indicates an item that you found.
Available:
Indicates an item that is available to be found.
Category
Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
Patient Data
Not Scored
A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case. Zachary LaFontaine Infant Well Visit Shadow health Subjective Data Collection
Confirmed Guardian’s Relationship

Finding:
Asked about relationship with patient

Finding:
Reports being Zachary’s mother
(Found)
Pro Tip: Confirming the patient’s relationship with their guardian ensures that you’re observing legal and ethical protections for patient privacy and that you’re speaking with someone who has access to their information.
Example Question:
Are you your son’s guardian?
Reason for Visit

Finding:
Established reason for visit

Finding:
Reports bringing Zachary in for a wellness visit
(Found)
Pro Tip: Determining the reason for a visit in the patient’s own words ensures that you understand what the patient wants from the visit. It also allows you to correctly document the visit’s purpose.
Example Question:
What bring you in to the clinic today?
Feeding

Finding:
Asked about Daanis’ feeding practices Zachary LaFontaine Infant Well Visit Shadow health Subjective Data Collection

Finding:
Reports breastfeeding Zachary
(Found)
Pro Tip: Feeding, diet, and nutrition are key components of infant wellness and have a direct impact on their development and health. Guardians and caretakers’ descriptions of how and what an infant is eating will allow you to detect and make sense of any developmental delays.
Example Question:
Are you breastfeeding your son?

Finding:
Reports offering both breasts
(Found)
xxxxx
Example Question:
Does your mother put your son down for naps?

Finding:
Reports that Zachary wakes up frequently on Tuesday and Thursday nights
(Available)
Pro Tip: Sleep and routine are key components of infant wellness. Insufficient, restless, or excessive sleep directly impacts an infant’s growth and development.
Example Question:
Does your son have trouble sleeping? Zachary LaFontaine Infant Well Visit Shadow health Subjective Data Collection

Finding:
Asked about sleep safety

Finding:
Reports Zachary sleeps in a cradleboard or a bassinet
(Found)
Pro Tip: Sleep and routine are key components of infant wellness. Insufficient, restless, or excessive sleep directly impacts an infant’s growth and development.
Example Question:
Where does your son sleep?

Finding:
Reports that Zachary sleeps swaddled on his back
(Found)
Pro Tip: Sleep and routine are key components of infant wellness. Insufficient, restless, or excessive sleep directly impacts an infant’s growth and development.
Example Question:
Do you swaddle your son?

Finding:
Reports that Zachary sleeps in an empty bassinet
(Found)
Pro Tip: Sleep and routine are key components of infant wellness. Insufficient, restless, or excessive sleep directly impacts an infant’s growth and development Zachary LaFontaine Infant Well Visit Shadow health Subjective Data Collection.
Example Question:
Does your son sleep with anything?

Finding:
Reports that Zachary sleeps in Daanis’ room
(Found)
Pro Tip: Sleep and routine are key components of infant wellness. Insufficient, restless, or excessive sleep directly impacts an infant’s growth and development.
Example Question:
Do you sleep with your son?

Finding:
Denies cosleeping with Zachary
(Available)
Pro Tip: Sleep and routine are key components of infant wellness. Insufficient, restless, or excessive sleep directly impacts an infant’s growth and development.
Example Question:
Do you cosleep with your son?
Elimination

Finding:
Asked about elimination

Finding:
Reports Zachary urinates 5 or 6 times a day
(Found)
Pro Tip: Elimination is a key component of infant wellness. The frequency and quality of an infant’s feces, urine, spit up, and vomit provide important information about their diet, health, and development.
Example Question:
How often does your son urinate?

Finding:
Reports Zachary defecates 3 times a day at most
(Found)
Pro Tip: Elimination is a key component of infant wellness. The frequency and quality of an infant’s feces, urine, spit up, and vomit provide important information about their diet, health, and development.
Example Question:
How often does your son defecate?

Finding:
Reports Zachary spits up infrequently
(Available)
Pro Tip: Elimination is a key component of infant wellness. The frequency and quality of an infant’s feces, urine, spit up, and vomit provide important information about their diet, health, and development Zachary LaFontaine Infant Well Visit Shadow health Subjective Data Collection.
Example Question:
How frequently does your son spit up?

Fxx
Pro Tip: Healthy infants usually develop along a predictable timeframe. Delayed or absent developmental milestones can be a sign of health conditions, disorders, or the need for changes in the guardian’s feeding practice, sleep schedule, and health promotion behavior.
Example Question:
What kinds of noises is your son making?

Finding:
Asked about auditory developmental milestone

Finding:
Reports that Zachary turns to look at noises
(Found)
Pro Tip: Healthy infants usually develop along a predictable timeframe. Delayed or absent developmental milestones can be a sign of health conditions, disorders, or the need for changes in the guardian’s feeding practice, sleep schedule, and health promotion behavior.
Example Question:
Does your son look when he hears something?

Finding:
Asked about gross motor developmental milestone

Finding:
Reports not purposefully doing tummy time
(Found)
Pro Tip: Healthy infants usually develop along a predictable timeframe. Delayed or absent developmental milestones can be a sign of health conditions, disorders, or the need for changes in the guardian’s feeding practice, sleep schedule, and health promotion behavior.
Example Question:
Are you familiar with tummy time?

Finding:
Reports that he seems to be able to lift his head
(Found)
Pro Tip: Healthy infants usually develop along a predictable timeframe. Delayed or absent developmental milestones can be a sign of health conditions, disorders, or the need for changes in the guardian’s feeding practice, sleep schedule, and health promotion behavior.
Example Question:
How often does your son lift his head up?
Maternal Health

Finding:
Asked about maternal health

Finding:
Reports busy personal schedule
(Found)
Pro Tip: A caretaker’s health and wellbeing has a significant impact on the health of their child, especially when they are a breastfeeding mother.
Example Question:
What is your schedule like?

Finding:
Reports that mother is helping with childcare
(Available)
Pro Tip: A caretaker’s health and wellbeing has a significant impact on the health of their child, especially when they are a breastfeeding mother.
Example Question:
Are you the only adult who lives in your home?

Finding:
Reports drinking sufficient water
(Found)
Pro Tip: A caretaker’s health and wellbeing has a significant impact on the health of their child, especially when they are a breastfeeding mother.
Example Question:
How much water do you drink?

Finding:
Reports eating healthy, high-calorie diet
(Available)
Pro Tip: A caretaker’s health and wellbeing has a significant impact on the health of their child, especially when they are a breastfeeding mother.
Example Question:
How is your diet and appetite doing?

Finding:
Reports insufficient sleep
(Found)
Pro Tip: A caretaker’s health and wellbeing has a significant impact on the health of their child, especially when they are a breastfeeding mother Zachary LaFontaine Infant Well Visit Shadow health Subjective Data Collection.
Example Question:
Do you get enough sleep?

Finding:
Asked about breast health

Finding:
Reports breasts feeling full before feeding
(Available)
Pro Tip: A caretaker’s health and wellbeing has a significant impact on the health of their child, especially when they are a breastfeeding mother.
Example Question:
Do your breasts feel full before feeding your son?

Finding:
Reports breasts don’t always feel empty after feeding
(Available)
Pro Tip: A caretaker’s health and wellbeing has a significant impact on the health of their child, especially when they are a breastfeeding mother.
Example Question:
Do your breasts ever feel empty?

Finding:
Denies frequent breast leaking
(Found)
Pro Tip: A caretaker’s health and wellbeing has a significant impact on the health of their child, especially when they are a breastfeeding mother.
Example Question:
Have you noticed your breasts leaking at all?

Finding:
Denies breast and nipple pain
(Available)
Pro Tip: A caretaker’s health and wellbeing has a significant impact on the health of their child, especially when they are a breastfeeding mother.
Example Question:
Do you have breast pain?

Finding:
Asked about maternal mental health

Finding:
Reports feeling overwhelmed
(Found)
Pro Tip: A caretaker’s health and wellbeing has a significant impact on the health of their child, especially when they are a breastfeeding mother.
Example Question:
How are your mood and energy right now?

Finding:
Reports minimal support network outside of family Zachary LaFontaine Infant Well Visit Shadow health Subjective Data Collection