Alcohol Use Disorder Rachel Adler shadow health Documentation
Medical Records / Digital Health Record
Charts
Table of Contents
Admission Note by Nurse
Student Records Patient Records
Main Concern
Hurt wrist from a car crash because of drinking too much alcohol.
Ms. Adler hurt her right wrist because she crashed her car while she was drunk. She also might hurt herself and talked about feeling very sad and not caring about living.
What Happened Recently
Rachel Adler is a 20-year-old Caucasian woman who drinks alcohol and feels anxious sometimes. Police brought her to the hospital after she crashed her car while she was drunk.
Rachel Adler is a 20-year-old Caucasian woman with a history of drinking alcohol and feeling anxious. Police brought her to the hospital last night after she crashed her car while she was drunk. Doctors found that she hurt her right wrist, and they saw that her alcohol level was 0.2% (which is higher than the legal limit for people under 21) when the accident happened. Ms. Adler said she didn’t remember what happened but was told she got a ticket for driving under the influence. She felt a lot of pain when she got to the hospital, but it got better when she took ibuprofen. Ms. Adler said she didn’t feel sick or throw up. She was admitted to the adult mental health unit because she showed signs of wanting to hurt herself. Alcohol Use Disorder: Rachel Adler’s Medical Records
Allergies
Allergic to peanuts, but no other allergies.
Allergic to peanuts, which makes her mouth and throat itchy, but she’s not allergic to anything else.
Past Health Information
No health problems
No health problems. She said she doesn’t use drugs for fun, and she doesn’t smoke.
Past Surgeries
Never had surgery before.
Never had surgery before.
Medicine History
Takes ibuprofen and Ortho Tri-Cyclen Lo, one pill every day.
Takes Ortho Tri-Cyclen Lo, one pill by mouth every day at 8 in the morning. She also sometimes takes ibuprofen for period pain.
Family Health History
Dad is healthy, mom has anxiety, and her mom’s dad had a problem with drinking too much alcohol.
Her mom has anxiety, her dad is healthy, and her mom’s dad drank too much alcohol.
Life Outside of Health
Goes to junior college, not in a relationship, doesn’t smoke or use illegal drugs, but drinks alcohol three times a week.
Goes to junior college, not in a relationship right now, has safe sex, doesn’t smoke or use illegal drugs, but drinks alcohol three times a week.
Thoughts
Sometimes thinks about not wanting to live.
Ms. Adler sometimes thinks about not wanting to live. She said she feels very sad and doesn’t care if she lives or dies. But she hasn’t tried to hurt herself, and she doesn’t have a plan to do it. She’s stressed about school and her relationship with her mom, especially because of the DUI and how she ended up in the hospital.
Seeing Things
Doesn’t have strange thoughts or do strange things.
Ms. Adler doesn’t seem to have any strange thoughts or do anything strange during the checkup. There’s no sign that she sees or hears things that aren’t real. Alcohol Use Disorder: Rachel Adler’s Medical Records
Alcohol Use Disorder Rachel Adler shadow health Documentation
Documentation / Electronic Health Record
Rachel Adler Alcohol Use Disorder shadow health Objective Data Collection
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 |
