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NR 509 Week 1 Shadow Health History Assignment DOCUMENTATION
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NR 509 Week 1 Shadow Health History Assignment DOCUMENTATION
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History Assignment | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/4119094History Assignment Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-October-2018
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/ Electronic Health Record
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Subjective Data Collection Document: Provider Notes
Objective Data Collection
Education & Empathy Document: Provider Notes
Documentation Student Documentation Model Documentation
Information Processing
Identifying Data & Reliability Ms. Jones is a pleasant, 28-year-old obese African
Health History Tips and American single woman who presents to establish
Tina JOnes is a nice and compliant 28 year old care and with a recent right foot injury. She is the
Tricks female. She came with an injury to her right primary source of the history. Ms. Jones offers
foot. She is coherenet and hapily answers information freely and without contradiction.
Self-Reflection questions and keeps eye contact. She seems Speech is clear and coherent. She maintains eye
very reliable. contact throughout the interview.
General Survey
The patient is alert and aware of her Ms. Jones is alert and oriented, seated upright on
surroundings. She sits up fine and is in no ditress, the examination table, and is in no apparent
just pain from her foot. She has good hygiene and distress. She is well-nourished, well-developed,
is dressed well. and dressed appropriately with good hygiene.
Chief Complaint
“I got this scrape on my foot a while ago, and I
A scrape on the ball of the right thought it would heal up on its own, but now it's
foot looking pretty nasty. And the pain is killing me!”
History Of Present Illness
Ms. Jones reports that a week ago she tripped
A week ago, the patient tripped on some stairs
while walking on concrete stairs outside, twisting
causing her to twist her ankle and get a scrape on
her right ankle and scraping the ball of her foot.
the ball of her right foot. She went to the ER where
She sought care in a local emergency department
x-rays found that the ankle was fine. They gave her
where she had x-rays that were negative; she was
tramadol to take for the pain as needed. The
treated with tramadol for pain. She has been
patient has been keeping the wound clean and
© Shadow Health® 2018 cleansing the site twice a day. She has been
https://www.coursehero.com/file/35688085/NR-509-History-Assignment-Documentation-Shadowpdf/
1 of 11/20/2018, 5:32
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