5/25/2020 Health History | Completed | Shadow Health
Health History Results | Completed
Health Assessment - August 2017, NUR3067C
Return to Assignment (/assignments/140509/)
Your Results Lab Pass (/assignment_attempts/2759705/lab_pass.p
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Document: Provider Notes
Objective Data Collection
Document: Provider Notes
Education & Empathy
Documentation
Student Documentation Model Documentation
Health History Tips and Tricks
Identifying Data & Reliability Ms. Jones is a pleasant, 28-year-old obese African American s
Lifespan woman who presents to establish care and with a recent right f
Ms. Tina Jones 28 year old , African American, single who presents
injury. She is the primary source of the history. Ms. Jones offers
to the clinic with concerns of her recent right foot injury. Ms. Jones
Self-Reflection information freely and without contradiction. Speech is clear an
is pleasant and good historian.
coherent. She maintains eye contact throughout the interview.
General Survey
Ms. Jones is alert and oriented, seated upright on the examinat
Ms. Jones is alert and oriented, no apparent distress, properly table, and is in no apparent distress. She is well-nourished, we
groomed. developed, and dressed appropriately with good hygiene.
Chief Complaint
Patient reports that she sustained a scraped at the plantar surface “I got this scrape on my foot a while ago, and I thought it would
of her foot. The wound is draining with pus, no fouly smell but the up on its own, but now it's looking pretty nasty. And the pain is
pain is bothering her, and the pain got worse of the last 2 days. killing me!”
Patient states that the "pain is killing me".
History Of Present Illness Ms. Jones reports that a week ago she tripped while walking on
concrete stairs outside, twisting her right ankle and scraping the
Patient states that she was doing down the back steps. She tripped,
of her foot. She sought care in a local emergency department
and caught the railing, and kind of turned her ankle. She scraped up
where she had x-rays that were negative; she was treated with
her foot on the edge of the step.
tramadol for pain. She has been cleansing the site twice a day.
She went to the ER with concerns that she fracture her ankle. While
has been applying antibiotic ointment and a bandage. She repo
in ER they xray the ankle and the foot , the result shows negative
that ankle swelling and pain have resolved but that the bottom
for fracture. She was sent with prescription of tramadol. Patient is
the foot is increasingly painful. The pain is described as “throbb
taking the pain medications three times a day. Patient states the
and “sharp” with weight bearing. She states her ankle “ached” b
pain is relieved by medication but only for a few hours, and then she
resolved. Pain is rated 7 out of 10 after a recent dose of tramad
starts feeling the throbbing pain. Patient states that she clean the
Pain is rated 9 with weight bearing. She reports that over the pa
wound with soap and water and put neosporin and wrap it with
two days the ball of the foot has become swollen and increasin
bandage twice a day. Ms. Jones states that the wound get worst.
red; yesterday she noted discharge oozing from the wound. Sh
The discharge in the wound is oozing, but clear drainage, and the
denies any odor from the wound. Her shoes feel tight. She has
wound feels warm and get more swollen. She reported to having a
been wearing slip-ons. She reports fever of 102 last night. She
fever with a temperature of 102 last night. Reported that about a
denies recent illness. Reports a 10-pound, unintentional weight
month ago she lose weight 10lbs without trying. No changes of diet
over the month and increased appetite. Denies change in diet o
and level of activity.
level of activity.
This study source was downloaded by 100000827506713 from CourseHero.com on 02-25-2022 02:55:03 GMT -06:00
https://app.shadowhealth.com/assignment_attempts/2759705 1/3
https://www.coursehero.com/file/62575576/Shadow-Health-Tina-Jones-Documentation-Electronic-Health-Recordpdf/
Health History Results | Completed
Health Assessment - August 2017, NUR3067C
Return to Assignment (/assignments/140509/)
Your Results Lab Pass (/assignment_attempts/2759705/lab_pass.p
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Document: Provider Notes
Objective Data Collection
Document: Provider Notes
Education & Empathy
Documentation
Student Documentation Model Documentation
Health History Tips and Tricks
Identifying Data & Reliability Ms. Jones is a pleasant, 28-year-old obese African American s
Lifespan woman who presents to establish care and with a recent right f
Ms. Tina Jones 28 year old , African American, single who presents
injury. She is the primary source of the history. Ms. Jones offers
to the clinic with concerns of her recent right foot injury. Ms. Jones
Self-Reflection information freely and without contradiction. Speech is clear an
is pleasant and good historian.
coherent. She maintains eye contact throughout the interview.
General Survey
Ms. Jones is alert and oriented, seated upright on the examinat
Ms. Jones is alert and oriented, no apparent distress, properly table, and is in no apparent distress. She is well-nourished, we
groomed. developed, and dressed appropriately with good hygiene.
Chief Complaint
Patient reports that she sustained a scraped at the plantar surface “I got this scrape on my foot a while ago, and I thought it would
of her foot. The wound is draining with pus, no fouly smell but the up on its own, but now it's looking pretty nasty. And the pain is
pain is bothering her, and the pain got worse of the last 2 days. killing me!”
Patient states that the "pain is killing me".
History Of Present Illness Ms. Jones reports that a week ago she tripped while walking on
concrete stairs outside, twisting her right ankle and scraping the
Patient states that she was doing down the back steps. She tripped,
of her foot. She sought care in a local emergency department
and caught the railing, and kind of turned her ankle. She scraped up
where she had x-rays that were negative; she was treated with
her foot on the edge of the step.
tramadol for pain. She has been cleansing the site twice a day.
She went to the ER with concerns that she fracture her ankle. While
has been applying antibiotic ointment and a bandage. She repo
in ER they xray the ankle and the foot , the result shows negative
that ankle swelling and pain have resolved but that the bottom
for fracture. She was sent with prescription of tramadol. Patient is
the foot is increasingly painful. The pain is described as “throbb
taking the pain medications three times a day. Patient states the
and “sharp” with weight bearing. She states her ankle “ached” b
pain is relieved by medication but only for a few hours, and then she
resolved. Pain is rated 7 out of 10 after a recent dose of tramad
starts feeling the throbbing pain. Patient states that she clean the
Pain is rated 9 with weight bearing. She reports that over the pa
wound with soap and water and put neosporin and wrap it with
two days the ball of the foot has become swollen and increasin
bandage twice a day. Ms. Jones states that the wound get worst.
red; yesterday she noted discharge oozing from the wound. Sh
The discharge in the wound is oozing, but clear drainage, and the
denies any odor from the wound. Her shoes feel tight. She has
wound feels warm and get more swollen. She reported to having a
been wearing slip-ons. She reports fever of 102 last night. She
fever with a temperature of 102 last night. Reported that about a
denies recent illness. Reports a 10-pound, unintentional weight
month ago she lose weight 10lbs without trying. No changes of diet
over the month and increased appetite. Denies change in diet o
and level of activity.
level of activity.
This study source was downloaded by 100000827506713 from CourseHero.com on 02-25-2022 02:55:03 GMT -06:00
https://app.shadowhealth.com/assignment_attempts/2759705 1/3
https://www.coursehero.com/file/62575576/Shadow-Health-Tina-Jones-Documentation-Electronic-Health-Recordpdf/
