Shadow Health Comprehensive Assess.docx - Document Provider Notes \u2013 NURS 6512 Name T Jones Comprehensive Assessment Type your narrative-style

Shadow Health Comprehensive Assess.docx - Document Provider...

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Name: Comprehensive Assessment Vitals Health History Identifying Data T. Jones Type your narrative-style documentation for each section of the assignment into the corresponding dialogue boxes below. When you are ready to submit your documentation, ‘Save As’ with this title format: “[LastName_FirstName] Shadow Health Documentation Template - Comprehensive - NURS 6512” 99.0 degrees F-128/82-78-15-98% Ht: 170 c m Wt: 84 kg BMI: 29 BGL: 100 Race: AA Gender: Female DOB: 2/17/1992 Age: 28 Document: Provider Notes – NURS 6512 C o p y r i g h t © 2 0 1 9 | | S h a d o w h e a l t h . c o m 1
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General Survey Reason for Visit She appears stated age. Fatigue or lethargy not observed. Alert and oriented to self, person, place, time, and situation. Pre-employment physical exam Document: Provider Notes – NURS 6512 C o p y r i g h t © 2 0 1 9 | | S h a d o w h e a l t h . c o m 2
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History of Present Illness A 28-year-old AA female presents to the clinic for a pre-employment physical. Her last physical was 4-5 months ago, when she received a pap smear. Last Hgb A1C drawn 2 weeks ago. She denies fever, chills, or fatigue. She denies any trauma history. Denies recent falls. Document: Provider Notes – NURS 6512 C o p y r i g h t © 2 0 1 9 | | S h a d o w h e a l t h . c o m 3
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Medications Allergies 1. Metformin 850 mg: 1 tablet orally, twice a day. Last taken this morning. Started 5 months ago. 2. Yaz (strength unknown): 1 tab orally, daily with breakfast, last this morning. Started 4 months ago. 3. Flovent 2 puffs, twice a day. Last this morning. Started 5 months ago. 4. Proventil, 2 puffs as needed: Last “maybe 3 months ago” after being around friend’s cat 5. Advil 200 mg: 2 tabs orally as needed for cramps. Last taken “maybe 6 weeks ago.” 6. Denies vitamins or herbal supplements Cats: Adverse reactions are and exacerbation of asthma symptoms, chest tightness and wheezing Dust: Side effects improved with daily inhaler
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