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1/12/202 Week 4: Comprehensive Assessment | Completed | Shadow
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, 1/12/202 Week 4: Comprehensive Assessment | Completed | Shadow
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Student Documentation Model Documentation
Identifying Data & Reliability Ms. Jones is a pleasant, 28-year-old African American
single wo who presents for a pre-employment physical.
Tina Jones is a 28 year old African American female She is the primary source of the history. Ms. Jones offers
unmarried. Identified patient by asking her to state her information freely and wit contradiction. Speech is clear
full name and DOB. and coherent. She maintains eye contact throughout
the interview.
General Survey
Ms. Jones is alert and oriented, seated upright on the
Tina Jones is alert, oriented. She is well-nourished and examinatio table, and is in no apparent distress. She is
developed. She presents with good hygiene and dressed well-nourished, well- developed, and dressed
appropriately. appropriately with good hygiene.
Reason for Visit
Ms. Jones states she was newly hired as an accounting "I came in because I'm required to have a recent
clerk and is here for a pre-employment physical as a physical exam the health insurance at my new job."
requirement for health insurance prior to her start date in
about 2 weeks.
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