Health Transcript, Subjective, Objective &
Documentation
Comprehensive Assessment Tina Jones Shadow
Health Transcript, Subjective, Objective &
Documentation
Transcript
All Lines (645)Interview Questions
(210)Statements (41)Exam Actions (394)
Hello, my name is . I will be Greet
conducting an interview and later 07/22/20
perform a physical exam. 5:37 PM EDT
Hey.
Question
What is your name? 07/22/20
5:37 PM EDT
Tina Jones.
Question
Your date of birth? 07/22/20
5:37 PM EDT
February 17th.
How old are you? Question
07/22/20
, 5:43 PM EDT
I’m 28.
Question
What brought you into the clinic
07/22/20
today?
5:43 PM EDT
I came in because I’m required to
have a recent physical exam for
the health insurance at my new
job.
Question
Do you have any current health
07/22/20
problem?
5:44 PM EDT
I don’t have anything specific
going on today. I mean, I still
have asthma and diabetes, but
both of those are under control.
I’m taking good care of my health
these days.
What is your new job?
Comprehensive Assessment Question
Tina Jones Shadow Health 07/22/20
Transcript, Subjective, Objective 5:44 PM EDT
& Documentation
,I’m going to be an Accounting
Clerk at Smith, Stevens, Stewart,
Silver & Company. I’ll be helping
a more experienced accountant
with her clients, and then
eventually I’ll get more
responsibility, and build my own
client list. I start in two weeks–I’m
really excited!
Empathize
That is great. 07/22/20
5:45 PM EDT
Thanks.
Question
When was your last physical
07/22/20
exam?
5:45 PM EDT
Let’s see . . . I had two doctor’s
appointments earlier this year.
About five months ago, I came in
here for a check-up, and the
nurse practitioner got me on
metformin. Then a few weeks
later I saw a gynecologist for a
pap smear.
, Question
What did your gynecologist say? 07/22/20
5:45 PM EDT
She said everything looked good,
except that I had PCOS, which
the nurse here had said was
possible. She started me on birth
control, and it seems to be
helping things.
Question
How often do you take birth
07/22/20
control?
5:48 PM EDT
I take it every morning, with
breakfast.
Question
What is the name of the birth
07/22/20
control pill you took?
5:49 PM EDT
They’re called Yaz.
Question
Has your menstrual cycle
07/22/20
improved since taking Yaz?
5:50 PM EDT
Now that I’m on the pill I’m
getting my period every month.