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Shadow Health Comprehensive Assessment Tina Jones -Documentation (Electronic Health Record)-2023
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Shadow Health Comprehensive Assessment Tina Jones -Documentation (Electronic Health Record)-2023
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By: heydare1 • 4 months ago
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10/29/2017 Comprehensive Assessment | Completed | Shadow Health 1/7 Shadow Health Comprehensive Assessment Tina Jones -Documentation (Electronic Health Record)-2023 Comprehensive Assessment Results | Turned In Advanced Health Assessment - September '17 , NREO81 NRE-662 01A Return to Assignment Your Results Lab Pass Documentation / Electronic Health Record Documentation Vitals Student Documentation Model Documentation 128/82 mm Hg (97.3 MAP) HP 78 99% SpO2 98.9 degrees F FVC 3.91 L FEV1 3.15 L FEV1/FVC - 0.81 • Height: 170 cm • Weight: 84 kg • BMI: 29.0 • Blood Glucose: 100 • RR: 15 • HR: 78 • BP: • Pulse Ox: 99% • Temperature: 99.0 F Health History Student Documentation Model Documentation Identifying Data & Reliability Able to state name and date of birth that matches EHR records. Oriented x3. (For the record, I did stop before starting asking questions. There should be a lapse in time. I was documenting) Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre- employment physical. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview. General Survey Ms. Jones is a 28 year old obese, African American woman who is clearly able to keep up with her ADLs. Her hair is braided, her clothes are clean, she seems to be able to keep up with hygiene. She does not seem to be in any acute distress. Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene. Overview Transcript Subjective Data Collection Objective Data Collection Documentation Plan My Exam Self-Reflection 10/29/2017 Comprehensive Assessment | Completed | Shadow Health 2/7The benefits of buying summaries with Stuvia:
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