Tina Jones HEENT Shadow HEalth Documentation.docx - Documentation Electronic Health Record Document Provider Notes Document Provider Notes Student

Tina Jones HEENT Shadow HEalth 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 female with a history of asthma and uncontrolled type 2 diabetes mellitus. She presents to the clinic today complaining of a sore throat, clear nasal discharge, and itchy/watery eyes that began a week ago. Her pain is a 4/10. She has allergies to penicillin and cats, but has never had seasonal allergies. States her sister has "hay fever." Social History: Denies tobacco use with no environmetal exposure. Social Alcohol use. No exposure to known allergens. She does not exercise. General: Denies fever, weight loss/gain, or fatigue. Head: Denies current headache or history of trauma. Eyes: Reports worsening vision over the past few years. Denies use of corrective lenses. Ears: Denies hearing loss or problems. Denies ear drainage. Nose: Reports Clear nasal drainage. Denies pain, sneezing, and itching. Mouth/Throat: No hoarseness. Reports Sore throat. Respiratory: Denies coughing and difficulty breathing. History of asthma. Asthma is at baseline with inhaler use 2 to 3 times per week. HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of sore, itchy throat, itchy eyes, and runny nose for the last week. She states that these symptoms started spontaneously and have been constant in nature. She does not note any specific aggravating symptoms, but states that her throat pain seems to be worse in the morning. She rates her throat pain as 4/10 and her throat itchiness as 5/10. She has treated her throat pain with occasional throat lozenges which has “helped a little”. She states that she has some soreness when swallowing, but
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