HEALTH NURSING DOCUMENTATION
ELECTRONIC HEALTH RECORD VERIFIED
RESPONSE SET 2026
◉ Social History. Answer: Never married, no children. Lived
independently since age 19, currently lives with mother and sister to
support family after death of father one year ago, anticipates moving out
in a few months. She works 32 hours/week as a supervisor at a printing
and shipping company and is in her last semester of a bachelor's of
accounting program. She hopes to advance to an accounting position
within her company. Has a car, cell phone, and computer. She receives
basic health insurance from work, but is deterred from healthcare due to
out-of-pocket costs. She is very active in her Baptist church, faith is
important to her, and church community is a large part of her social
network. No exercise. She wears her seat belt, drives frequently. Guns
are locked up. No tobacco. Occasional alcohol (10 - 12 drinks/month).
No concerns about alcoholism. Occasional cannabis use from age 15 to
age 21. She drinks four caffeinated drinks/day (diet soda). No foreign
travel. No pets. Not currently in an intimate relationship, ended a three-
year serious monogamous relationship two years ago. She plans on
getting married and having children someday. She denies suicidal and
homicidal ideation.
◉ Family History (3 generations). Answer: • Father: died at age 58 in a
car accident, history of hypertension, high cholesterol, and type 2
diabetes