NR 509 Week 4 Shadow Health Documentation / Electronic Health Record 2020/2021
Documentation / Electronic Health Record
Documentation
Vitals
Student Documentation Model Documentation
• Height: 170 cm • Weight: 84 kg • BMI: 29.0 • Blood
BP 128/82 HR 78 RR 15 O2 99% on RA T 37.2 C Glucose: 100 • RR: 15 • HR: 78 • BP: • Pulse
Ox: 99% • Temperature: 99.0 F
Health History
Student Documentation Model Documentation
Identifying Data & Reliability Ms. Jones is a pleasant, 28-year-old African American
single woman who presents for a pre-employment
ID- Tina Jones is a 28 year old African American woman physical. She is the primary source of the history. Ms.
who appears to be stated age. She is a reliable Jones offers information freely and without
historian. contradiction. Speech is clear and coherent. She
maintains eye contact throughout the interview.
, Student Documentation Model Documentation
General Survey
Ms. Jones is alert and oriented, seated upright on the
MS Jones is a well groomed, well dressed, pleasant examination table, and is in no apparent distress. She is
woman who makes eye contact and answers well-nourished, well-developed, and dressed
appropriately to qustions. appropriately with good hygiene.
Reason for Visit
“I came in because I'm required to have a recent
Physical examination physical exam for the health insurance at my new job.”
Ms. Jones reports that she recently obtained
employment at Smith, Stevens, Stewart, Silver &
Company. She needs to obtain a pre-employment
physical prior to initiating employment. Today she
denies any acute concerns. Her last healthcare visit
was 4 months ago, when she received her annual
History of Present Illness
gynecological exam at Shadow Health General Clinic.
Ms. Jones states that the gynecologist diagnosed her
Comprehensive health assessment for pre-employment
with polycystic ovarian syndrome and prescribed oral
physical examination
contraceptives at that visit, which she is tolerating well.
She has type 2 diabetes, which she is controlling with
diet, exercise, and metformin, which she just started 5
months ago. She has no medication side effects at this
time. She states that she feels healthy, is taking better
care of herself than in the past, and is looking forward
to beginning the new job.
Documentation / Electronic Health Record
Documentation
Vitals
Student Documentation Model Documentation
• Height: 170 cm • Weight: 84 kg • BMI: 29.0 • Blood
BP 128/82 HR 78 RR 15 O2 99% on RA T 37.2 C Glucose: 100 • RR: 15 • HR: 78 • BP: • Pulse
Ox: 99% • Temperature: 99.0 F
Health History
Student Documentation Model Documentation
Identifying Data & Reliability Ms. Jones is a pleasant, 28-year-old African American
single woman who presents for a pre-employment
ID- Tina Jones is a 28 year old African American woman physical. She is the primary source of the history. Ms.
who appears to be stated age. She is a reliable Jones offers information freely and without
historian. contradiction. Speech is clear and coherent. She
maintains eye contact throughout the interview.
, Student Documentation Model Documentation
General Survey
Ms. Jones is alert and oriented, seated upright on the
MS Jones is a well groomed, well dressed, pleasant examination table, and is in no apparent distress. She is
woman who makes eye contact and answers well-nourished, well-developed, and dressed
appropriately to qustions. appropriately with good hygiene.
Reason for Visit
“I came in because I'm required to have a recent
Physical examination physical exam for the health insurance at my new job.”
Ms. Jones reports that she recently obtained
employment at Smith, Stevens, Stewart, Silver &
Company. She needs to obtain a pre-employment
physical prior to initiating employment. Today she
denies any acute concerns. Her last healthcare visit
was 4 months ago, when she received her annual
History of Present Illness
gynecological exam at Shadow Health General Clinic.
Ms. Jones states that the gynecologist diagnosed her
Comprehensive health assessment for pre-employment
with polycystic ovarian syndrome and prescribed oral
physical examination
contraceptives at that visit, which she is tolerating well.
She has type 2 diabetes, which she is controlling with
diet, exercise, and metformin, which she just started 5
months ago. She has no medication side effects at this
time. She states that she feels healthy, is taking better
care of herself than in the past, and is looking forward
to beginning the new job.
