case study
A DVANCED H EALTH A SSESSMENT
Comprehensive Assessment - TINA JONES™
“ I came in because I’m required to have a recent
physical exam for the health insurance at my new job.
Module 9 - Comprehensive Assessment
ly
Ms. Jones is a pleasant, 29-year-old African American single woman who presents for a pre-employment physical. She
n
coherent. She maintains eye contact throughout the interview.
Timeframe: 18 months after establishing primary care (Age: 29.5)
Reason for visit: Patient requests a complete health assessment for a pre-employment physical.
O
Learning Objectives
e
Develop strong communication skills
• Interview the patient to elicit subjective health information about her health and health history
s
• Ask relevant follow-up questions to evaluate patient condition
• Demonstrate empathy for patient perspectives, feelings, and sociocultural background
U
• Identify opportunities to educate the patient
Document accurately and appropriately
r
• Document subjective data using professional terminology
• Organize appropriate documentation in the EHR
to
Demonstrate clinical reasoning skills
c
• Organize all components of an interview
• Assess risk for disease, infection, injury, and complications
Module Features
•
ts r u
Student Performance Index - This style of rubric contains subjective and objective data categories. Subjective
data categories include interview questions and patient data. Objective data categories include examination
n
and patient data.
I
Underlying Diagnoses
Tina still has asthma and diabetes, but both are under control. She presents with no complaint.
© Shadow Health® 072015 || ShadowHealth.com
**For instructor use only**
This study source was downloaded by 100000830772748 from CourseHero.comPage
on 07-25-2022
1 of 3 15:47:56 GMT -05:00
https://www.coursehero.com/file/63416251/Final-Shadow-Health-pdfpdf/
A DVANCED H EALTH A SSESSMENT
Comprehensive Assessment - TINA JONES™
“ I came in because I’m required to have a recent
physical exam for the health insurance at my new job.
Module 9 - Comprehensive Assessment
ly
Ms. Jones is a pleasant, 29-year-old African American single woman who presents for a pre-employment physical. She
n
coherent. She maintains eye contact throughout the interview.
Timeframe: 18 months after establishing primary care (Age: 29.5)
Reason for visit: Patient requests a complete health assessment for a pre-employment physical.
O
Learning Objectives
e
Develop strong communication skills
• Interview the patient to elicit subjective health information about her health and health history
s
• Ask relevant follow-up questions to evaluate patient condition
• Demonstrate empathy for patient perspectives, feelings, and sociocultural background
U
• Identify opportunities to educate the patient
Document accurately and appropriately
r
• Document subjective data using professional terminology
• Organize appropriate documentation in the EHR
to
Demonstrate clinical reasoning skills
c
• Organize all components of an interview
• Assess risk for disease, infection, injury, and complications
Module Features
•
ts r u
Student Performance Index - This style of rubric contains subjective and objective data categories. Subjective
data categories include interview questions and patient data. Objective data categories include examination
n
and patient data.
I
Underlying Diagnoses
Tina still has asthma and diabetes, but both are under control. She presents with no complaint.
© Shadow Health® 072015 || ShadowHealth.com
**For instructor use only**
This study source was downloaded by 100000830772748 from CourseHero.comPage
on 07-25-2022
1 of 3 15:47:56 GMT -05:00
https://www.coursehero.com/file/63416251/Final-Shadow-Health-pdfpdf/
