Tina Jones HEENT Shadow Health Documentation
Documentation / Electronic Health Record
• Document: Provider Notes
Document: Provider Notes
Student Documentation Model Documentation
HPI: Ms. Jones is a pleasant 28-year-old African American woman
Subjective who presented to the clinic with complaints of sore, itchy throat,
Ms. Jones is a 28 year old African American female with a history itchy eyes, and runny nose for the last week. She states that these
of asthma and uncontrolled type 2 diabetes mellitus. She presents symptoms started spontaneously and have been constant in nature.
to the clinic today complaining of a sore throat, clear nasal She does not note any specific aggravating symptoms, but states
discharge, and itchy/watery eyes that began a week ago. Her pain that her throat pain seems to be worse in the morning. She rates her
is a 4/10. She has allergies to penicillin and cats, but has never had throat pain as 4/10 and her throat itchiness as 5/10. She has treated
seasonal allergies. States her sister has "hay fever." Social History: her throat pain with occasional throat lozenges which has “helped a
Denies tobacco use with no environmetal exposure. Social Alcohol little”. She states that she has some soreness when swallowing, but
use. No exposure to known allergens. She does not exercise. otherwise no other associated symptoms. She states that her nose
General: Denies fever, weight loss/gain, or fatigue. Head: Denies “runs all day” and is clear discharge. She has not attempted any
current headache or history of trauma. Eyes: Reports worsening treatment for her nasal symptoms. She states that her eyes are
vision over the past few years. Denies use of corrective lenses. constantly itchy and she has not attempted any eye specific
Ears: Denies hearing loss or problems. Denies ear drainage. Nose: treatment. She denies cough and recent illness. She has had no
Reports Clear nasal drainage. Denies pain, sneezing, and itching. exposures to sick individuals. She denies changes in her hearing,
Mouth/Throat: No hoarseness. Reports Sore throat. Respiratory: vision, and taste. She denies fevers, chills, and night sweats. She
has never been diagnosed with seasonal allergies, but does note
Documentation / Electronic Health Record
• Document: Provider Notes
Document: Provider Notes
Student Documentation Model Documentation
HPI: Ms. Jones is a pleasant 28-year-old African American woman
Subjective who presented to the clinic with complaints of sore, itchy throat,
Ms. Jones is a 28 year old African American female with a history itchy eyes, and runny nose for the last week. She states that these
of asthma and uncontrolled type 2 diabetes mellitus. She presents symptoms started spontaneously and have been constant in nature.
to the clinic today complaining of a sore throat, clear nasal She does not note any specific aggravating symptoms, but states
discharge, and itchy/watery eyes that began a week ago. Her pain that her throat pain seems to be worse in the morning. She rates her
is a 4/10. She has allergies to penicillin and cats, but has never had throat pain as 4/10 and her throat itchiness as 5/10. She has treated
seasonal allergies. States her sister has "hay fever." Social History: her throat pain with occasional throat lozenges which has “helped a
Denies tobacco use with no environmetal exposure. Social Alcohol little”. She states that she has some soreness when swallowing, but
use. No exposure to known allergens. She does not exercise. otherwise no other associated symptoms. She states that her nose
General: Denies fever, weight loss/gain, or fatigue. Head: Denies “runs all day” and is clear discharge. She has not attempted any
current headache or history of trauma. Eyes: Reports worsening treatment for her nasal symptoms. She states that her eyes are
vision over the past few years. Denies use of corrective lenses. constantly itchy and she has not attempted any eye specific
Ears: Denies hearing loss or problems. Denies ear drainage. Nose: treatment. She denies cough and recent illness. She has had no
Reports Clear nasal drainage. Denies pain, sneezing, and itching. exposures to sick individuals. She denies changes in her hearing,
Mouth/Throat: No hoarseness. Reports Sore throat. Respiratory: vision, and taste. She denies fevers, chills, and night sweats. She
has never been diagnosed with seasonal allergies, but does note
