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

Shadow Health Focused Exam Abdominal Documentation.docx -...

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Documentation / Electronic Health Record Document: Vitals Document: Provider Notes Document: Vitals Vitals 08:00 Blood Pressure 110/70 O2 Sat 99 Pulse 92 Resp. Rate 16 Temperature 37 Pain Rating 6 out of 10 Document: Provider Notes
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Student Documentation Model Documentation Subjective Ms. Park is 78-year-old Korean woman, complant of "having pain in  belly and having difficulty going to bathroom". She had diarrhea  three days ago and has not had a bowel movement since. Her  daughter insisted she come tot he clinic to check. She reports that  the pain has increased in the past 2-3 days. She describes the  symptoms as generalized pain and discomfort in the lower  abdomen. She also describes pain as dull, crampy, and bloating.  She rates the pain at 6 out of 10. Dhe denies blood in stool, any GI  history disorder. She had 2 colonoscopies done, last colonoscopy  and pap smear were 10 years ago. Last diarrhea describe as very  loose and watery; her usual bowel movement usually everyday. She reports recent slight decreases in frequency of urination due to  decrease water intake, urine color is darker than usual. She reports  that she usually drinks 6-8 glass of water a day. Denies any GI  disorder, GERD, ulcer, appendicitis, liver, spleen problem. She  reports that she had 2 surgeries in the past; C-section at age of 40  and chelecystectomy at age of 42 with no complication. Typically 
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  • Fall '15
  • Objective pronoun, Ms. Park, LLQ

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