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

Shadow Health Musculoskeletal Documentation.docx -...

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Documentation / Electronic Health Record Document: Provider Notes Document: Provider Notes Student Documentation Model Documentation Subjective Ms. Jones is pleasant 28-year African-American female. She presents complaing of pain in lower back that make "hard to get things done". She is taking two pills of Advil for pain every 5-6 hours, started night after injury. Her initial pain scale was 6 or 8 out of 10; current pain scale 5; states "the pain didn't seem like it was going away" Sitting up and moving around make pain worst; Lying flat and Advil make help relieve symptoms. She describes pain as "an ache", hurts more when press, little stiffness. Denies burning, sharp, radiating Use Flovent daily inhaler every day and proventil rescue inhaler. HPI: Ms. Jones presents to the clinic that began 3 days ago after she “twea box while helping a friend move. She boxes before this event without incid weight of the box that caused her pain back and bilateral buttocks, is a const and does not radiate. The pain is aggr 7/10) and decreased by rest and lying 4/10). The pain has not changed over has treated with 2 over the counter ib hours. Her current pain is a 5/10, but can decrease her pain to 2-3/10. She d
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