Comprehensive Assessment Results | Turned In.
Patient Assessment and Health Literacy - January 2019, NUR 325
Return to Assignment
Your Results Lab Pass
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Documentation
Objective Data Collection
Documentation Vitals
Plan My Exam
Student Documentation Model Documentation
Self-Reflection
• Height: 170 cm
• Weight: 84 kg
Vitals • BMI: 29.0
• Blood Glucose: 100
BP 128/82, Temp 37.2, Pulse 78 Resps 15 SpO2 • RR: 15
99%. • HR: 78
• BP:
• Pulse Ox: 99%
• Temperature: 99.0 F
Health History
Student Documentation Model Documentation
Ms. Jones is a pleasant, 28-year-old African
Identifying Data & Reliability American single woman who presents for a pre-
employment physical. She is the primary source of
Provides full name and verifies date of birth. the history. Ms. Jones offers information freely and
without contradiction. Speech is clear and coherent.
She maintains eye contact throughout the 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 100000842568006 from CourseHero.com on 09-06-2022 01:17:35 GMT -05:00
https://www.coursehero.com/file/38062631/Comprehensive-Assessment-Completed-Shadow-Healthpdf/
, Student Documentation Model Documentation
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
History of Present Illness was 4 months ago, when she received her annual
gynecological exam at Shadow Health General
REports no current health issues. Hx of Asthma Clinic. Ms. Jones states that the gynecologist
(Albuterol); Diabetes (Metformin) and Polycystic diagnosed her with polycystic ovarian syndrome
Ovaria Syndrome (Yaz). Patient rates current health and prescribed oral contraceptives at that visit,
at an 8/10. 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.
Medications • Metformin, 850 mg PO BID (last use: this morning)
• Drospirenone and ethinyl estradiol PO QD (last
Metformin 850 mg PO BID; use: this morning)
Albuterol number of mcg not available on visit; 2-3 • Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn
puffs INH PRN / asthma; (last use: yesterday)
Yaz 1 tab PO daily. • Acetaminophen 500-1000 mg PO prn (headaches)
Advil OTC 200 mg PO PRN • Ibuprofen 600 mg PO TID prn (menstrual cramps:
last taken 6 weeks ago)
• Penicillin: rash
Allergies • Denies food and latex allergies
• Allergic to cats and dust. When she is exposed to
PCN, pediatric onset, rash / urticaria.
allergens she states that she has runny nose, itchy
CAts; asthma exacerbator, runny nose.
and swollen eyes, and increased asthma
symptoms.
This study source was downloaded by 100000842568006 from CourseHero.com on 09-06-2022 01:17:35 GMT -05:00
https://www.coursehero.com/file/38062631/Comprehensive-Assessment-Completed-Shadow-Healthpdf/
Patient Assessment and Health Literacy - January 2019, NUR 325
Return to Assignment
Your Results Lab Pass
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Documentation
Objective Data Collection
Documentation Vitals
Plan My Exam
Student Documentation Model Documentation
Self-Reflection
• Height: 170 cm
• Weight: 84 kg
Vitals • BMI: 29.0
• Blood Glucose: 100
BP 128/82, Temp 37.2, Pulse 78 Resps 15 SpO2 • RR: 15
99%. • HR: 78
• BP:
• Pulse Ox: 99%
• Temperature: 99.0 F
Health History
Student Documentation Model Documentation
Ms. Jones is a pleasant, 28-year-old African
Identifying Data & Reliability American single woman who presents for a pre-
employment physical. She is the primary source of
Provides full name and verifies date of birth. the history. Ms. Jones offers information freely and
without contradiction. Speech is clear and coherent.
She maintains eye contact throughout the 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 100000842568006 from CourseHero.com on 09-06-2022 01:17:35 GMT -05:00
https://www.coursehero.com/file/38062631/Comprehensive-Assessment-Completed-Shadow-Healthpdf/
, Student Documentation Model Documentation
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
History of Present Illness was 4 months ago, when she received her annual
gynecological exam at Shadow Health General
REports no current health issues. Hx of Asthma Clinic. Ms. Jones states that the gynecologist
(Albuterol); Diabetes (Metformin) and Polycystic diagnosed her with polycystic ovarian syndrome
Ovaria Syndrome (Yaz). Patient rates current health and prescribed oral contraceptives at that visit,
at an 8/10. 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.
Medications • Metformin, 850 mg PO BID (last use: this morning)
• Drospirenone and ethinyl estradiol PO QD (last
Metformin 850 mg PO BID; use: this morning)
Albuterol number of mcg not available on visit; 2-3 • Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn
puffs INH PRN / asthma; (last use: yesterday)
Yaz 1 tab PO daily. • Acetaminophen 500-1000 mg PO prn (headaches)
Advil OTC 200 mg PO PRN • Ibuprofen 600 mg PO TID prn (menstrual cramps:
last taken 6 weeks ago)
• Penicillin: rash
Allergies • Denies food and latex allergies
• Allergic to cats and dust. When she is exposed to
PCN, pediatric onset, rash / urticaria.
allergens she states that she has runny nose, itchy
CAts; asthma exacerbator, runny nose.
and swollen eyes, and increased asthma
symptoms.
This study source was downloaded by 100000842568006 from CourseHero.com on 09-06-2022 01:17:35 GMT -05:00
https://www.coursehero.com/file/38062631/Comprehensive-Assessment-Completed-Shadow-Healthpdf/
