2
COMPREHENSIVE ASSESSMENT
RESULTS | TURNED IN
Patient Assessment and Health Literacy - January 2019, NUR 325
Return to Assignment
Your Results
Lab Pass
Documentation / Electronic Health Record
Overview
Transcript
Subjective Data Collection Documentation
Objective Data Collection
Documentation
Vitals
Plan My Exam
Student Documentation Model Documentation
• Height: 170 cm
• Weight: 84 kg
• BMI: 29.0
• Blood Glucose: 100
Vitals • RR: 15
• HR: 78
• BP:
BP 128/82, Temp 37.2, Pulse 78 Resps 15 • Pulse Ox: 99%
SpO2 • Temperature: 99.0 F
99%.
Health History
Student Documentation Model Documentation
https://www.coursehero.com/file/38062631/Comprehensive-Assessment-Completed-Shadow-Healthpdf/
, 2
Ms. Jones is a pleasant, 28-year-old African
American single woman who presents for a pre-
Identifying Data & Reliability employment physical. She is the primary source of
the history. Ms. Jones offers information freely and
without contradiction. Speech is clear and
Provides full name and verifies date of coherent. She maintains eye contact throughout the
birth. interview.
General Survey
Ms. Jones is alert and oriented, seated upright on
Ms. Jones is a pleasant, well-groomed 28 year old the examination table, and is in no apparent
AFrican American female wearing glasses to correct distress. She is well-nourished, well-developed, and
nearsightedness, dressed appropriately with good hygiene.
Reason for Visit
"I came in because I'm required to have a recent
Ms. Jones presents to clinic today for a pre- physical exam for the health insurance at my new
employment physical. job."
This study source was downloaded by 100000848934517 from CourseHero.com on 06-27-2022 12:53:23 GMT -05:00
https://www.coursehero.com/file/38062631/Comprehensive-Assessment-Completed-Shadow-Healthpdf/
COMPREHENSIVE ASSESSMENT
RESULTS | TURNED IN
Patient Assessment and Health Literacy - January 2019, NUR 325
Return to Assignment
Your Results
Lab Pass
Documentation / Electronic Health Record
Overview
Transcript
Subjective Data Collection Documentation
Objective Data Collection
Documentation
Vitals
Plan My Exam
Student Documentation Model Documentation
• Height: 170 cm
• Weight: 84 kg
• BMI: 29.0
• Blood Glucose: 100
Vitals • RR: 15
• HR: 78
• BP:
BP 128/82, Temp 37.2, Pulse 78 Resps 15 • Pulse Ox: 99%
SpO2 • Temperature: 99.0 F
99%.
Health History
Student Documentation Model Documentation
https://www.coursehero.com/file/38062631/Comprehensive-Assessment-Completed-Shadow-Healthpdf/
, 2
Ms. Jones is a pleasant, 28-year-old African
American single woman who presents for a pre-
Identifying Data & Reliability employment physical. She is the primary source of
the history. Ms. Jones offers information freely and
without contradiction. Speech is clear and
Provides full name and verifies date of coherent. She maintains eye contact throughout the
birth. interview.
General Survey
Ms. Jones is alert and oriented, seated upright on
Ms. Jones is a pleasant, well-groomed 28 year old the examination table, and is in no apparent
AFrican American female wearing glasses to correct distress. She is well-nourished, well-developed, and
nearsightedness, dressed appropriately with good hygiene.
Reason for Visit
"I came in because I'm required to have a recent
Ms. Jones presents to clinic today for a pre- physical exam for the health insurance at my new
employment physical. job."
This study source was downloaded by 100000848934517 from CourseHero.com on 06-27-2022 12:53:23 GMT -05:00
https://www.coursehero.com/file/38062631/Comprehensive-Assessment-Completed-Shadow-Healthpdf/
