Shadow Health Gastrointestinal Documentation.docx - Documentation Electronic Health Record Document Provider Notes Document Provider Notes Student

Shadow Health Gastrointestinal Documentation.docx -...

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Documentation / Electronic Health Record Document: Provider Notes Document: Provider Notes Student Documentation Model Documentation Subjective Ms. Jones is a 28-year-old African American woman who complaints of upper stmach pain after eating. She reports the pain started about a month ago; pain gets worse laying down, pain starts within 10-15 minutes every time after eat. She has been taken antacid (Tums) for pain relieves, try to only take them when the pain worse than usual; "starts with two, and then I chew a couple more if I need to". She reports that stomach pains everyday, sitting up and take antacid help relieve pain. She denies nausea, vomiting with pain. Current pain scale is 1-2 and 5 after eat; 0-10 10 being worse. She reports pain location is upper stomach "right below my breastbone, in the middle". She denies any abdominal tenderness, stomach cramps,gassy, and bloating. She reports the bowel movemennt once a day or every other day. Pian is right in the center of the stomach, between the belly button and ribs. denies radiating pain. The pain gets worse when eating spicy, big meal, and lying down. She states eat french fries as snack or treat; usual breakfast as cereal, toast, muffin, or pumpkin bread, or pick up something on the way. Her usual lunch as sandwich, chips, or pretzels, or French fries. She report has been burping after eat. Denies flatus or weight changes. She denies history of GI disease include liver, spleen, gallbladder, appendic, kidney, bladder, stomach cancer, any GI surgery, and stomach ulcer. She reports having bowel movement every two days which is normal for her. Denies any pain while bowel movement. She has not noticed any blood or mucus in the stool, reports light or dark brown color, and normal consistency. Denies diarrhea. She reports frequency of urination as every hour or two and get up to urinate due to more consumes water. Describes urine clor as light yellow or clear, deniens pain while urination.
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  • Fall '15
  • Gastroesophageal reflux disease

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