Abdominal Pain Focused Exam Documentation.docx - Documentation Electronic Health Record Document Vitals Document Provider Notes Document Provider Notes

Abdominal Pain Focused Exam Documentation.docx -...

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Documentation / Electronic Health RecordDocument: VitalsDocument: Provider NotesDocument: Provider NotesStudent DocumentationModel DocumentationSubjectiveCC: "uncomfortable" down in "my lower belly" associated with diarrhea two days ago and no bowel movement since Pain began 5 days ago and is described as "dull" and "crampy", associated with bloating that increases with movment and eating and little to no relief with rest. Diarrhea reported 3 days ago that lasted x1 day x 3-4 times described as "loose" and "watery". Pt reports lack of appetite for 3 days. Denies weight loss or weight gain. States "whole belly is uncomfortable"but pain is mainly located in lower abdomen. Pt is post-menopausal with history of hysterectomy. No bowel movement x5 days other than diarrhea 2 days ago. Reports normal daily bowel movements up until 5 days ago. Describes being less thirsty than usual; drinks 5 to 6 glasses of water per day. Daily fruit and vegetables for breakfast, lunch and dinner; sometimes skips lunch; denies use of laxatives, anti-diarrhea medications, or fiber supplements Ms. Park reports that she is “having pain in her belly.” She experienced mild diarrhea three days ago and has not had a bowel movement since. She reports that she has been feeling some abdominal discomfort for close to a week, but the pain has increased in the past 2-3 days. She now rates her pain at 6 out of 10, and describes it as dull and crampy. She reports her pain level at the onset at 3 out of 10. She is also experiencing bloating. She did not feel her symptoms warranted a trip to the clinic but her daughter insisted she come. She describes her symptoms primarily as generalized discomfort in the abdomen, and states that her lower abdomen is the location of the pain. She
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