Focused Exam: Abdominal Pain | Completed | Shadow Health https://maryville.shadowhealth.com/assignment_attempts/9342
EXAM
Focused Exam: Abdominal Pain Results | Completed
Advanced Health Assessment - MU - January 2021, nurs_612_20w_21/sp
Return to Assignment (/assignments/458632/)
Your Results Turn In (/assignment_attempts/9342257/choose)
Reopen (/assignment_attempts/9342257/reopen)
Lab Pass (/assignment_attempts/9342257/lab_pass.pdf)
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Document: Vitals Document: Provider Notes
Objective Data Collection
Document: Provider Notes
Education & Empathy
Documentation Student Documentation Model Documentation
Self-Reflection
Ms. Park reports that she is “having pain in her belly.” She has not
had a bowel movement in about five days; she has not had any
diarrhea since a food poisoning incident six months ago. She reports
that she has been feeling some abdominal discomfort for close to a
week, but the pain has increased in the past 2-3 days. She now rates
her pain at 6 out of 10, and describes it as dull and crampy. She
reports her pain level at the onset at 3 out of 10. She is also
Subjective experiencing bloating. She did not feel her symptoms warranted a trip
to the clinic but her daughter insisted she come. She describes her
(No Documentation Made) symptoms primarily as generalized discomfort in the abdomen, and
states that her lower abdomen is the location of the pain. She denies
nausea and vomiting, blood or mucus in stool, rectal pain or bleeding,
or recent fever. She denies vaginal bleeding or discharge. Reports no
history of inflammatory bowel disease or GERD. Denies family history
of GI disorders. Her appetite has decreased over the last few days
and she is taking small amounts of water and fluids. Previously she
reports regular brown soft stools every day to every other day.
Support
This study source was downloaded by 100000869052700 from CourseHero.com on 07-17-2023 08:39:43 GMT -05:00
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EXAM
Focused Exam: Abdominal Pain Results | Completed
Advanced Health Assessment - MU - January 2021, nurs_612_20w_21/sp
Return to Assignment (/assignments/458632/)
Your Results Turn In (/assignment_attempts/9342257/choose)
Reopen (/assignment_attempts/9342257/reopen)
Lab Pass (/assignment_attempts/9342257/lab_pass.pdf)
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Document: Vitals Document: Provider Notes
Objective Data Collection
Document: Provider Notes
Education & Empathy
Documentation Student Documentation Model Documentation
Self-Reflection
Ms. Park reports that she is “having pain in her belly.” She has not
had a bowel movement in about five days; she has not had any
diarrhea since a food poisoning incident six months ago. She reports
that she has been feeling some abdominal discomfort for close to a
week, but the pain has increased in the past 2-3 days. She now rates
her pain at 6 out of 10, and describes it as dull and crampy. She
reports her pain level at the onset at 3 out of 10. She is also
Subjective experiencing bloating. She did not feel her symptoms warranted a trip
to the clinic but her daughter insisted she come. She describes her
(No Documentation Made) symptoms primarily as generalized discomfort in the abdomen, and
states that her lower abdomen is the location of the pain. She denies
nausea and vomiting, blood or mucus in stool, rectal pain or bleeding,
or recent fever. She denies vaginal bleeding or discharge. Reports no
history of inflammatory bowel disease or GERD. Denies family history
of GI disorders. Her appetite has decreased over the last few days
and she is taking small amounts of water and fluids. Previously she
reports regular brown soft stools every day to every other day.
Support
This study source was downloaded by 100000869052700 from CourseHero.com on 07-17-2023 08:39:43 GMT -05:00
1 of 2 https://www.coursehero.com/file/85279223/Focused-Exam-Abdominal-Pain-Doccumentationpdf/ 3/13/2021, 10:52
