10/29/2017 Comprehensive Assessment | Completed | Shadow Health 1/7 Comprehensive Assessment Results | Turned In Advanced Health Assessment - September '17 , NREO81 NRE-662 01A Return to Assignment Your Results Lab Pass 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:128 / 82 • 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 Documentation / Electronic Health Record
10/29/2017 Comprehensive Assessment | Completed | Shadow Health 2/7 Student Documentation Model Documentation Reason for Visit Ms. Jones is here for a head-to-toe exam for insurance purposes for her new job. “I came in because I'm required to have a recent physical exam for the health insurance at my new job.” History of Present Illness No present illness, does not admit to symptoms and states she is "doing well, thanks!" Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. She needs to obtain a pre-employment physical prior to initiating employment. Today she denies any acute concerns. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. She has no medication side effects at this time. She states that she feels healthy, is taking better care of herself than in the past, and is looking forward to beginning the new job.
- Summer '17
- Dr. Iris Malone
- Comprehensive Assessment, Diabetic neuropathy, Model Documentation, Student Documentation