NR 509 Tina Jones Comprehensive Health Assessment

Documentation / Electronic Health Record

Documentation

Vitals

Student Documentation	Model Documentation
BP 128/82 P 78 RR 15 Temp 37.2 O2 99% Weight 84kg Height 5’6″ BMI 29 B 100	• Height: 170 cm • Weight: 84 kg • BMI: 29.0 • Blood Glucose: 100 • RR: 15 • HR: 78 • BP:128 / 82 • Pulse Ox: 99% • Temperature: 99.0 F

Health History

Student Documentation	Model Documentation
Identifying Data & Reliability Ms. Jones is a pleasant 28 year old African American female who presents to the clinic today for a physical for employment. Pt’s responses are appropriate, maintains eye contact throughout exam.	Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview.
General Survey Pt in no apparent distress, alert and oriented x 4, calm and cooperative, appropriately dressed with good hygiene.	Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene.
Reason for Visit Pt states she needs an employment physical for a new job she will be beginning in two weeks.	“I came in because I’m required to have a recent physical exam for the health insurance at my new job.”
History of Present Illness Pt presents to the clinic for an employment physical that she will begin in two weeks. Pt denies any medical issues or concerns. … CONT	Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. …. CONT
Medications Flovent 110mcg 2 puffs BID Albuterol 90mcg 2 puffs PRN Metformin 850mg PO BID Advil OTC regular strength PRN for cramps Yaz PO QD birth control	• Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning) … CONT
Allergies PCN- skin rash Cats- exacerbates asthma Dust-exacerbates asthma, itchy	• Penicillin: rash • CONT
Medical History Asthma- … CONT	Asthma diagnosed at age 2 1/2. … CONT
Health Maintenance Since last encounter … CONT	Last Pap smear 4 months ago. Last eye exam three months ago. Last dental exam five months ago. … CONT
Family History Mother 50- high cholesterol and HTN Father- deceased at 58, high cholesterol, diabetes, and HTN Maternal grandmother- deceased at 73 from stroke, had HTN and high cholesterol Maternal grandfather- deceased at 80 from heart attack, had HTN and cholesterol Paternal grandmother 82- high cholesterol, HTN Paternal grandfather- deceased from colon cancer mid sixties, had high cholesterol, diabetes, and HTN Sister 15- Asthma Brother 26- obese Paternal uncle- alcoholism Denies any other family medical history.	• Mother: age 50, hypertension, elevated cholesterol • Father: deceased in car accident one year ago at age 58, hypertension, high cholesterol, and type 2 diabetes • Brother (Michael, 25): overweight • Sister (Britney, 14): asthma • Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol • Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol • Paternal grandmother: still living, age 82, hypertension • Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes • Paternal uncle: alcoholism • Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, thyroid problems
Social History Pt just graduated college with an accounting degree, never married, no children, pt in a relationship with a male, pt denies smoking or drug use, occasional alcohol with friends. Pt likes to read, currently lives at home with her mother and sister but has plans to move out next month.	Never married, no children. … CONT
Mental Health History Pt denies any … CONT	Reports decreased stress and improved coping abilities …. CONT
Review of Systems – General General: no weakness, fatigue or fevers. Positive weight loss of 10 pounds. Skin: no rashes, lesions, dry skin, itching or color changes, no dandruff, or changes in nails. HEENT: … CONT	No recent or frequent illness, … CONT

HEENT

Student Documentation	Model Documentation
Subjective Denies headaches, eye pain or issues, no sinus pressure, ,,, CONT	Reports no current headache and no history of head injury or acute visual changes. … CONT
Objective No obvious injuries or bruising. Head is normocephalic. ,,, CONT	Head is normocephalic, atraumatic. Bilateral eyes with equal hair distribution on lashes and eyebrows, … CONT

Student Documentation

Model Documentation

Subjective

Denies headaches, eye pain or issues, no sinus pressure, ,,, CONT

Reports no current headache and no history of head injury or acute visual changes. … CONT

Objective

No obvious injuries or bruising. Head is normocephalic. ,,, CONT

Head is normocephalic, atraumatic. Bilateral eyes with equal hair distribution on lashes and eyebrows, … CONT

Respiratory

Student Documentation	Model Documentation
Subjective Pt denies shortness of breath, difficult breathing, wheezing or cough. Pt has history of asthma. Denies sinus pressure or rhinnorhea.	Reports no shortness of breath, wheezing, chest pain, dyspnea, or cough.
Objective Peak flow x3: … CONT	Chest is symmetric … CONT

Student Documentation

Model Documentation

Subjective

Pt denies shortness of breath, difficult breathing, wheezing or cough. Pt has history of asthma. Denies sinus pressure or rhinnorhea.

Reports no shortness of breath, wheezing, chest pain, dyspnea, or cough.

Objective

Peak flow x3: … CONT

Chest is symmetric … CONT

Cardiovascular

Student Documentation	Model Documentation
Subjective Pt denies chest pain, palpitations, or edema. No history of anemia or easy bruising.	Reports no palpitations, tachycardia, easy bruising, or edema.
Objective S1, S2 heard with normal rate and rythm, no murmurs or gallops noted on auscultation. … CONT	Heart rate is regular, S1, S2, without murmurs, gallops, or rubs. … CONT

Student Documentation

Model Documentation

Subjective

Pt denies chest pain, palpitations, or edema. No history of anemia or easy bruising.

Reports no palpitations, tachycardia, easy bruising, or edema.

Objective

S1, S2 heard with normal rate and rythm, no murmurs or gallops noted on auscultation. … CONT

Heart rate is regular, S1, S2, without murmurs, gallops, or rubs. … CONT

Abdominal

Student Documentation	Model Documentation
Subjective Pt denies any nausea, vomiting, diarrhea, constipation, abdominal pain or discomfort. … CONT	Gastrointestinal: … CONT.
Objective Abdomen no visible bruising or lesions, protuberant,… CONT	Abdomen protuberant,… CONT

Student Documentation

Model Documentation

Subjective

Pt denies any nausea, vomiting, diarrhea, constipation, abdominal pain or discomfort. … CONT

Gastrointestinal: … CONT.

Objective

Abdomen no visible bruising or lesions, protuberant,… CONT

Abdomen protuberant,… CONT

Musculoskeletal

Student Documentation	Model Documentation
Subjective Pt denies no joint or muscle pain, no weakness or edema.	Reports no muscle pain, joint pain, muscle weakness, or swelling.
Objective No obvious injuries … CONT	Strength 5/5… CONT

Student Documentation

Model Documentation

Subjective

Pt denies no joint or muscle pain, no weakness or edema.

Reports no muscle pain, joint pain, muscle weakness, or swelling.

Objective

No obvious injuries … CONT

Strength 5/5… CONT

Neurological

Student Documentation	Model Documentation
Subjective Pt denies any numbness or tingling sensations, … CONT	Reports no dizziness, … CONT
Objective Graphesthesia, stereognosis intact. Pt alert and oriented x 4. … CONT	Normal graphesthesia, … CONT

Student Documentation

Model Documentation

Subjective

Pt denies any numbness or tingling sensations, … CONT

Reports no dizziness, … CONT

Objective

Graphesthesia, stereognosis intact. Pt alert and oriented x 4. … CONT

Normal graphesthesia, … CONT

Skin, Hair & Nails

Student Documentation	Model Documentation
Subjective Pt denies rashes, … CONT	Reports improved acne due to … CONT
Objective No obvious injuries, lacerations, rashes, dandruff, or bruising. Pt’s hair well groomed with even hair distribution. No nail deformities noted in all extremities, clear with no ridges. Excessive hair growth on umbilicus, thin hair growth on upper lip.	Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. Nails fre

Student Documentation

Model Documentation

Subjective

Pt denies rashes, … CONT

Reports improved acne due to … CONT

Objective

No obvious injuries, lacerations, rashes, dandruff, or bruising. Pt’s hair well groomed with even hair distribution. No nail deformities noted in all extremities, clear with no ridges. Excessive hair growth on umbilicus, thin hair growth on upper lip.

Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. Nails fre

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Criteria

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Pts

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This criterion is linked to a Learning Outcome Subjective Data, Organization, Communication, and Summary (DCE Score or transcript) _9172

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