Document: Provider Notes – NURS 6512
tina
Name: Manvir Pannu
Health History
Introduction
A complete history of patient named with Tina jones; 28 years old female was completed in shadow
health assessment. Ms. Tina jones came in through the emergency department with her mom for
injury of right foot. Patient came back to clinic for follow up visit for right foot wound.
Identifying Data
Patient Tina jones is twenty-eight-year-old African American patient. Patient observe seated in
upright position in examination table. She examined for further evaluation of her right foot injury.
Ms. Tina jones was primary source of information. Patient was cooperative with staff. Her speech
was clear and coherent. She maintains good eye contact with staff through the interview process.
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1
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, Document: Provider Notes – NURS 6512
General: Is she alert and oriented x 4, no acute respiratory distress. Patient appears to be in foot pain.
Patient reported pain level of 7/10. Patients describe his pain as throbbing and pain is sharp when attempts
to stand. Patient present fair hygiene. Appropriate dressed according to weather. Patient has no issues in
dietary pattern.
General Survey
Chief Complaint
Patient came into clinic with chief complaint of right foot wound. Right foot throbbing pain on rest and pain
is sharp when she is trying to stand up.
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2
C o p y r i g h t © 2 0 1 9 || S h a d o w h e a l t h . c o m
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tina
Name: Manvir Pannu
Health History
Introduction
A complete history of patient named with Tina jones; 28 years old female was completed in shadow
health assessment. Ms. Tina jones came in through the emergency department with her mom for
injury of right foot. Patient came back to clinic for follow up visit for right foot wound.
Identifying Data
Patient Tina jones is twenty-eight-year-old African American patient. Patient observe seated in
upright position in examination table. She examined for further evaluation of her right foot injury.
Ms. Tina jones was primary source of information. Patient was cooperative with staff. Her speech
was clear and coherent. She maintains good eye contact with staff through the interview process.
This study source was downloaded by 100000830772748 from CourseHero.com on 02-23-2022 05:44:07 GMT -06:00
1
C o p y r i g h t © 2 0 1 9 || S h a d o w h e a l t h . c o m
https://www.coursehero.com/file/77624445/PannuManvirWeek4-Tina-Jones-Health-Assessment-Soap-note-1docx/
, Document: Provider Notes – NURS 6512
General: Is she alert and oriented x 4, no acute respiratory distress. Patient appears to be in foot pain.
Patient reported pain level of 7/10. Patients describe his pain as throbbing and pain is sharp when attempts
to stand. Patient present fair hygiene. Appropriate dressed according to weather. Patient has no issues in
dietary pattern.
General Survey
Chief Complaint
Patient came into clinic with chief complaint of right foot wound. Right foot throbbing pain on rest and pain
is sharp when she is trying to stand up.
This study source was downloaded by 100000830772748 from CourseHero.com on 02-23-2022 05:44:07 GMT -06:00
2
C o p y r i g h t © 2 0 1 9 || S h a d o w h e a l t h . c o m
https://www.coursehero.com/file/77624445/PannuManvirWeek4-Tina-Jones-Health-Assessment-Soap-note-1docx/
