NR 509 Shadow Health Documentation / Electronic Health Record 2017
10/29/201
7
NR 509 Shadow Health Documentation / Electronic Health Record
Comprehensive Assessment Results | Turned In
Advanced Health Assessment - September '17 , NREO81 NRE-662 01A
Return to Assignment
Your
Lab Pass
Results
Overvie
Documentation / Electronic Health Record
w
Transcri Documentation
pt
Subjective Data Vitals
Collection
Objective Data
Student Documentation Model Documentation
Collection
Documentation
•Height: 170 cm
128/82 mm Hg (97.3 •Weight: 84 kg
MAP) HP 78 •BMI: 29.0
99% SpO2 •Blood Glucose: 100
98.9 degrees F •RR: 15
FVC 3.91 L •HR: 78
FEV1 3.15 L •BP:
FEV1/FVC - •Pulse Ox: 99%
0.81 •Temperature: 99.0 F
Health History
Student Documentation Model Documentation
Identifying Data & Reliability
Able to state name and date of birth that
Ms. Jones is a pleasant, 28-year-old African
matches EHR records. Oriented x3.
American single woman who presents for a
pre- employment physical. She is the primary
source of the history. Ms. Jones offers
(For the record, I did stop before starting
information freely and without contradiction.
asking questions. There should be a lapse
Speech is clear and coherent. She maintains
in time. I was documenting)
eye contact throughout the interview.
General Survey
Ms. Jones is a 28 year old obese, African Ms. Jones is alert and oriented, seated upright
American woman who is clearly able to keep on the examination table, and is in no
up with her ADLs. Her hair is braided, her apparent distress. She is well-nourished, well-
clothes are clean, she seems to be able to developed, and dressed appropriately with
keep up with hygiene. She does not seem to good hygiene.
be in any acute distress.
https://app.shadowhealth.com/ 1/7
assignment_attempts/2841794
https://www.coursehero.com/file/32969532/comp-docpdf/
, NR 509 Shadow Health Documentation / Electronic Health Record 2017
10/29/201
7
This study source was downloaded by 100000829818949 from CourseHero.com on 09-18-2021 15:47:16 GMT -05:00
https://app.shadowhealth.com/ 2/7
assignment_attempts/2841794
https://www.coursehero.com/file/32969532/comp-docpdf/
10/29/201
7
NR 509 Shadow Health Documentation / Electronic Health Record
Comprehensive Assessment Results | Turned In
Advanced Health Assessment - September '17 , NREO81 NRE-662 01A
Return to Assignment
Your
Lab Pass
Results
Overvie
Documentation / Electronic Health Record
w
Transcri Documentation
pt
Subjective Data Vitals
Collection
Objective Data
Student Documentation Model Documentation
Collection
Documentation
•Height: 170 cm
128/82 mm Hg (97.3 •Weight: 84 kg
MAP) HP 78 •BMI: 29.0
99% SpO2 •Blood Glucose: 100
98.9 degrees F •RR: 15
FVC 3.91 L •HR: 78
FEV1 3.15 L •BP:
FEV1/FVC - •Pulse Ox: 99%
0.81 •Temperature: 99.0 F
Health History
Student Documentation Model Documentation
Identifying Data & Reliability
Able to state name and date of birth that
Ms. Jones is a pleasant, 28-year-old African
matches EHR records. Oriented x3.
American single woman who presents for a
pre- employment physical. She is the primary
source of the history. Ms. Jones offers
(For the record, I did stop before starting
information freely and without contradiction.
asking questions. There should be a lapse
Speech is clear and coherent. She maintains
in time. I was documenting)
eye contact throughout the interview.
General Survey
Ms. Jones is a 28 year old obese, African Ms. Jones is alert and oriented, seated upright
American woman who is clearly able to keep on the examination table, and is in no
up with her ADLs. Her hair is braided, her apparent distress. She is well-nourished, well-
clothes are clean, she seems to be able to developed, and dressed appropriately with
keep up with hygiene. She does not seem to good hygiene.
be in any acute distress.
https://app.shadowhealth.com/ 1/7
assignment_attempts/2841794
https://www.coursehero.com/file/32969532/comp-docpdf/
, NR 509 Shadow Health Documentation / Electronic Health Record 2017
10/29/201
7
This study source was downloaded by 100000829818949 from CourseHero.com on 09-18-2021 15:47:16 GMT -05:00
https://app.shadowhealth.com/ 2/7
assignment_attempts/2841794
https://www.coursehero.com/file/32969532/comp-docpdf/
