Tina Jones Comprehensive Assessment/Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

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Tina Jones Comprehensive
Assessment/Comprehensive Assessment Tina Jones
Shadow Health Transcript, Subjective, Objective &
Documentation



Comprehensive Assessment Tina Jones Shadow Health Transcript,
Subjective, Objective & Documentation
Transcript

All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394)
Greet
Hello, my name is Tammy. I will be conducting an interview and 07/22/20
a physical exam. 5:37 PM
EDT


Hey.


Question
07/22/20
What is your name?
5:37 PM
EDT


Tina Jones.


Question
07/22/20
What is your date of birth?
5:37 PM
EDT


February 17th.


Question
How old are you? 07/22/20
5:43 PM
EDT


I’m 28.

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Question
07/22/20
What brings you into the clinic today? 5:43 PM
EDT


I came in because I’m required to have a recent physical exam for
the health insurance at my new job.

Question
07/22/20
Do you have any current health problem? 5:44 PM
EDT


I don’t have anything specific going on today. I mean, I still have
asthma and diabetes, but both of those are under control. I’m
taking good care of my health these days.

Question
07/22/20
What is your new job? 5:44 PM
EDT

I’m going to be an Accounting Clerk at Smith, Stevens, Stewart,
Silver & Company. I’ll be helping a more experienced
accountant with her clients, and then eventually I’ll get more
responsibility, and build my own client list. I start in two weeks–
I’m really excited!
Empathize
07/22/20
That is great. 5:45 PM
EDT



Thanks.


Question
07/22/20
When was your last physical exam? 5:45 PM
EDT

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Let’s see . . . I had two doctor’s appointments earlier this year.
About five months ago, I came in here for a check-up, and the
nurse practitioner got me on metformin. Then a few weeks later
I saw a gynecologist for a pap smear.

Question
07/22/20
What did your gynecologist say? 5:45 PM
EDT


She said everything looked good, except that I had PCOS, which
the nurse here had said was possible. She started me on birth
control, and it seems to be helping things.

Question
07/22/20
How often do you take birth control? 5:48 PM
EDT


I take it every morning, with breakfast.


Question
07/22/20
What is the name of the birth control pill you took? 5:49 PM
EDT



They’re called Yaz.


Question
07/22/20
Has your menstrual cycle improved since taking Yaz? 5:50 PM
EDT



Now that I’m on the pill I’m getting my period every month.

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Empathize
07/22/20
That is great. I am glad you are having your period every month. 5:50 PM
EDT



Thanks.


Question
07/22/20
How long have you had asthma? 5:51 PM
EDT



I’ve had asthma a long time. . . since I was really little.


Question
07/22/20
What age were you diagnosed with asthma? 5:51 PM
EDT


My doctor told me when I was pretty little… I think I was about
two and a half? I used to have a lot of trouble with asthma
attacks back then.

Empathize
07/22/20
I am sorry about the experience. 5:52 PM
EDT


Thanks.

Question
07/22/20
How do you manage your asthma? 5:52 PM
EDT