NR 509 Tina Jones Comprehensive Health Assessment Documentation / Electronic Health Record:
Documentation
Vitals
Height: 170 cm
Weight: 84 kg
BMI: 29.0
Blood Glucose: 100
Respiratory Rate (RR): 15
Heart Rate (HR): 78
Blood Pressure (BP): 128/82
Pulse Oximetry (Pulse Ox): 99%
Temperature: 99.0°F
Health History
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. Patient’s responses are appropriate, and she maintains eye contact throughout the exam.
General Survey
Patient is 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
Patient 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
Patient presents to the clinic for an employment physical that she will begin in two weeks. Patient denies any medical issues or concerns.
Medications
Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning)
Albuterol 90 mcg 2 puffs PRN
Metformin 850mg PO BID
Advil OTC regular strength PRN for cramps
Yaz PO QD birth control
Allergies
Penicillin: skin rash
Medical History
Asthma diagnosed at age 2 1/2.
Health Maintenance
Since our last encounter…
Last Pap smear 4 months ago.
Last eye exam was three months ago.
Last dental exam was five months ago.
Family 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
Never married, no children.
Currently in a relationship with a male.
Denies smoking or drug use.
Occasional alcohol with friends.
Likes to read.
Currently lives at home with her mother and sister but has plans to move out next month.
Mental Health History
Denies any…
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
Subjective
Reports no current headache and no history of head injury or acute visual changes.
Objective
No obvious injuries or bruising.
Head is normocephalic.
Bilateral eyes with equal hair distribution on lashes and eyebrows…
Respiratory
Subjective
Patient denies shortness of breath, difficult breathing, wheezing, or cough. Patient has a history of asthma. Denies sinus pressure or rhinorrhea.
Objective
Peak flow x3: …
Chest is symmetric…
Cardiovascular
Subjective
Patient denies chest pain, palpitations, or edema. No history of anemia or easy bruising.
Objective
S1, S2 heard with normal rate and rhythm, no murmurs or gallops noted on auscultation…
Heart rate is regular, S1, S2, without murmurs, gallops, or rubs…
Abdominal
Subjective
Gastrointestinal: …
Patient denies any nausea, vomiting, diarrhea, constipation, abdominal pain, or discomfort…
Objective
Abdomen no visible bruising or lesions, protuberant,…
Abdomen protuberant,…
Musculoskeletal
Subjective
Patient denies joint or muscle pain, weakness, or edema.
Reports no muscle pain, joint pain, muscle weakness, or swelling.
Objective
No obvious injuries…
Strength 5/5…
Neurological
Subjective
Patient denies any numbness or tingling sensations,…
Reports no dizziness,…
Objective
Graphesthesia, stereognosis intact. Patient alert and oriented x 4,…
Normal graphesthesia,…
Skin, Hair & Nails
Subjective
Patient denies rashes,…
Reports improved acne due to…
Objective
Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck.
Nails free…
No obvious injuries, lacerations, rashes, dandruff, or bruising. Patient’s hair is 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.
Shadow Health Physical Assessment Rubric:
Subjective Data, Organization, Communication, and Summary
Above Average: Comprehensive introduction with expectations of the exam verbalized; questions worded in a non-judgmental way; professional language exercised; questions well-organized; appropriate closing with summary of findings verbalized to the patient.
Objective Data, Physical Examination, Interpretation of Findings, Assessment, and Documentation
Above Average: Physical assessment documentation includes all relevant body systems; all pertinent normal and abnormal findings identified; documentation reflects professional language; treatment plan includes each component (diagnostics, medication, education, consultation/referral, and follow-up planning).
Self-Reflection
Above Average: Responds to three of the three reflection post questions; provides analysis of performance; reflection posts written using professional language; reflection posts demonstrate insight.
Description of criterion
