Nurs6512 Tina Jones Documentation GRADED
A
Documentation / Electronic Health
Record
Document: Provider Notes
Document: Provider Notes
Identifying
Student Data & Reliability
Documentation Model Documentation
Name: Tina Jones Age: 28 Sex: Female Race: African N/A
American Historian: patient
General Survey
Miss Jones is alert, awake, and oriented. She appears well nourished. She appears in moderate pain to her
N/A
Chief Complaint
Patint presents for an initial primary care visit complaining of an N/A
infected wound.
History Of Present Illness N/A
Tina Jones is a 28 year old African American female who presents today with an infected foot wound. Th
This study source was downloaded by 100000815611969 from CourseHero.com on 02-20-2023 00:44:22 GMT -06:00
https://www.coursehero.com/file/57952192/Nurs6512-Tina-Jones-Documentationdocx/
, Nurs6512 Tina Jones Documentation GRADED
A
Student Documentation Model Documentation
She reports the scrape and pain getting progressively worse and constant in the last few days. She reports
Medications
1. Tramadol 50 mg TID, Last dose 2 tablets priorto arrival.
2. Proventil inhaler 90 micrograms, 2-3 puffs, 2-3 times a
week and as needed. Last dose was 3 days ago when she was
at cousin's house who had cats. 3. Tylenol 500mg for
headache, usually 1-2 tablets at night before bed. Last dose 2 N/A
tabs prior to arrival. 4. Advil 200 mg for cramps takes up to
three times a day. Last dose was 3 weeks ago. 5. Metformin,
unknown dosage and frequency, last taken 3 years ago.
Stopped taking because she felt sick and gassy.
Allergies
N/Arash, hives 3. Dust- asthma att
1. Cats - difficulty breathings, sneezing itchy eyes 2. Penicillin- as a child,
Medical History
1. Asthma, diagnosed as a child at about 2.5 years old. 2.
Diabetes, type 2, diagnosed 4 years ago. Uncontrolled. She took
metformin when first diagnosed but stopped 3 years ago and just N/A
watches her diet and avoids sweets. Last lab test for diabetes
was 6 months after diagnosed. Denies any surgical history.
Health Maintenance N/A
Miss Jones' last visit to her primary doctor for a physical exam was about two years ago. Her last dental c
This study source was downloaded by 100000815611969 from CourseHero.com on 02-20-2023 00:44:22 GMT -06:00
https://www.coursehero.com/file/57952192/Nurs6512-Tina-Jones-Documentationdocx/
A
Documentation / Electronic Health
Record
Document: Provider Notes
Document: Provider Notes
Identifying
Student Data & Reliability
Documentation Model Documentation
Name: Tina Jones Age: 28 Sex: Female Race: African N/A
American Historian: patient
General Survey
Miss Jones is alert, awake, and oriented. She appears well nourished. She appears in moderate pain to her
N/A
Chief Complaint
Patint presents for an initial primary care visit complaining of an N/A
infected wound.
History Of Present Illness N/A
Tina Jones is a 28 year old African American female who presents today with an infected foot wound. Th
This study source was downloaded by 100000815611969 from CourseHero.com on 02-20-2023 00:44:22 GMT -06:00
https://www.coursehero.com/file/57952192/Nurs6512-Tina-Jones-Documentationdocx/
, Nurs6512 Tina Jones Documentation GRADED
A
Student Documentation Model Documentation
She reports the scrape and pain getting progressively worse and constant in the last few days. She reports
Medications
1. Tramadol 50 mg TID, Last dose 2 tablets priorto arrival.
2. Proventil inhaler 90 micrograms, 2-3 puffs, 2-3 times a
week and as needed. Last dose was 3 days ago when she was
at cousin's house who had cats. 3. Tylenol 500mg for
headache, usually 1-2 tablets at night before bed. Last dose 2 N/A
tabs prior to arrival. 4. Advil 200 mg for cramps takes up to
three times a day. Last dose was 3 weeks ago. 5. Metformin,
unknown dosage and frequency, last taken 3 years ago.
Stopped taking because she felt sick and gassy.
Allergies
N/Arash, hives 3. Dust- asthma att
1. Cats - difficulty breathings, sneezing itchy eyes 2. Penicillin- as a child,
Medical History
1. Asthma, diagnosed as a child at about 2.5 years old. 2.
Diabetes, type 2, diagnosed 4 years ago. Uncontrolled. She took
metformin when first diagnosed but stopped 3 years ago and just N/A
watches her diet and avoids sweets. Last lab test for diabetes
was 6 months after diagnosed. Denies any surgical history.
Health Maintenance N/A
Miss Jones' last visit to her primary doctor for a physical exam was about two years ago. Her last dental c
This study source was downloaded by 100000815611969 from CourseHero.com on 02-20-2023 00:44:22 GMT -06:00
https://www.coursehero.com/file/57952192/Nurs6512-Tina-Jones-Documentationdocx/
