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Week 9 - Comprehensive Assessment, Tina Jones - REQUIRED
Results | Turned In
Advanced Health Assessment and Diagnostic Reasoning - NP (Section N-12) - February 2021, nurs6512-
usw1.31747.202150
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Your
Results
Overvi
Documentation / Electronic Health Record
ew
Transc Documentation
ript
Subjective Data
Collection
Objective Data
Collection
Vitals
Documentation
Student Documentation Model Documentation
Program Competency
Progress
Vitals
Initials: T.J. Age: 28 Race: B Gender: F
VS: T 37.2 (oral) BP 128/82 N/A
(manual) P 78 RR 15 O2 99%
(RA) Ht. 5'7" (stated)
Wt. 198.41
(standing scale)
Spirometer
1.78/1.549
Health History
Student Documentation Model Documentation
Identifying Data & Reliability
primary source
Miss Jones is a 28 y/o BF who presents to of data collection
the clinic for a pre- employment physical. and is a reliable
She is polite, cooperative, and speech is historian for this
clear and appropriate to context. Makes exam.
appropriate eye contact. Miss Jones is
unaccompanied for this visit. She is the
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, 5/2/202 Week 9 - Comprehensive Assessment, Tina Jones - REQUIRED | Completed |
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N/A
General Survey
Miss Jones is a well-dressed, polite,
moderately obese female. N/A
She is AAO x 3. She answers questions
appropriately and appears to be in no acute
distress or discomfort. Her VS are stable and
she denies current pain or distress.
Reason for Visit
The patient presents to the clinic for a pre- N/A
employment physical exam.
Support
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