Documentation / Electronic Health Record Documentation Vitals Student Documentation Model Documentation BP 128/82 P 78 RR 15 Temp 37.2 O2 99% Weight 84kg Height 5'6" BMI 29 BS 100 • 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 Ms. Jones is a pleasant 28 year old African American female who presents to the clinic today for a physical for employment. Pt's responses are appropriate, maintains eye contact throughout exam. 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.
Student Documentation Model Documentation General Survey Pt in no apparent distress, alert and oriented x 4, calm and cooperative, appropriately dressed wtih good hygiene. 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. Reason for Visit Pt states she needs an employment physical for a new job she will be beginning in two weeks. “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 Pt presents to the clininc for an employment physical that she will begin in two weeks. Pt denies any medical issues or concerns. Since last visit pt has had her annual PAP smear resulting diagnosis of PCOS with treatment using birth control, had her annual eye exam resulting in prescription glasses, pt states her diabetes is now controlled with medication and exercise. Pt. states she is eating healthier and has reduced her soda intake. Pt's perception of health and self is good. 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.
Student Documentation Model Documentation Medications Flovent 110mcg 2 puffs BID Albuterol 90mcg 2 puffs PRN Metformin 850mg PO BID Advil OTC regular strength PRN for cramps Yaz PO QD birth control • Fluticasone propionate, 110 mcg 2 puffs BID (last use: this
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- Spring '19
- Grandparent, Model Documentation, Student Documentation , Shadow Health Tina Jones