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 Complaint

Sprained 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 Illness

Rachel Adler is a 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 an MVA in which she was noted to be under the influence of alcohol and had an injured to 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 was noted when ibuprofen was administered. Ms. Adler denies any nausea or vomiting. Admitted to adult mental health unit based on positive assessment for self-harm. Alcohol Use Disorder Rachel Adler shadow health Documentation

Allergies

Peanut allergy NKDA

Peanuts, the reaction is itchy mouth and throat NKDA

Past Medical History

No medical issues

Alcohol Use Disorder Rachel Adler shadow health Documentation

No medical issues Deny use of recreational drugs, denies tobacco use

Past Surgical History

No past surgeries.

No past surgical procedures

Medication History

Ibuprofen 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 History

Father: 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 History

Junior 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 a 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 Content

Passive 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 Disturbances

No 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

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