NR 509 Tina Jones Comprehensive Health Assessment
Documentation / Digital Health Document
Documentation
Vitals
Scholar Documentation Mannequin Documentation
BP 128/82 P 78 RR 15 Temp 37.2 O2 99% Weight 84kg Top 5’6″ BMI 29 BS 100 • Top: 170 cm • Weight: 84 kg • BMI: 29.zero • Blood Glucose: 100 • RR: 15 • HR: 78 • BP:128 / 82 • Pulse Ox: 99% • Temperature: 99.zero F
Health Historical past
Scholar Documentation Mannequin Documentation
Figuring out Knowledge & Reliability
Ms. Jones is a pleasing 28 yr previous African American feminine who presents to the clinic at this time for a bodily for employment. Pt’s responses are applicable, maintains eye contact all through examination.
Ms. Jones is a pleasing, 28-year-old African American single girl who presents for a pre-employment bodily. She is the first supply of the historical past. Ms. Jones provides data freely and with out contradiction. Speech is evident and coherent. She maintains eye contact all through the interview.
Common Survey
Pt in no obvious misery, alert and oriented x four, calm and cooperative, appropriately dressed wtih good hygiene.
Ms. Jones is alert and oriented, seated upright on the examination desk, and is in no obvious misery. She is well-nourished, well-developed, and dressed appropriately with good hygiene.
Cause for Go to
Pt states she wants an employment bodily for a brand new job she will likely be starting in two weeks.
“I got here in as a result of I’m required to have a latest bodily examination for the medical health insurance at my new job.”
Historical past of Current Sickness
Pt presents to the clininc for an employment bodily that she’s going to start in two weeks. Pt denies any medical points or issues. … CONT
Ms. Jones experiences that she just lately obtained employment at Smith, Stevens, Stewart, Silver & Firm. …. CONT
Drugs
Flovent 110mcg 2 puffs BID Albuterol 90mcg 2 puffs PRN Metformin 850mg PO BID Advil OTC common power PRN for cramps Yaz PO QD contraception
• Fluticasone propionate, 110 mcg 2 puffs BID (final use: this morning) … CONT
Allergic reactions
PCN- pores and skin rash Cats- exacerbates bronchial asthma Mud-exacerbates bronchial asthma, itchy
• Penicillin: rash • CONT
Medical Historical past
Bronchial asthma- … CONT
Bronchial asthma recognized at age 2 1/2. … CONT
Health Upkeep
Since final encounter … CONT
Final Pap smear four months in the past. Final eye examination three months in the past. Final dental examination 5 months in the past. … CONT
Household Historical past
Mom 50- excessive ldl cholesterol and HTN Father- deceased at 58, excessive ldl cholesterol, diabetes, and HTN Maternal grandmother- deeased at 73 from stroke, had HTN and excessive ldl cholesterol Maternal grandfather- deceased at 80 from coronary heart assault, had HTN and ldl cholesterol Paternal grandmother 82- excessive ldl cholesterol, HTN Paternal grandfather- deceased from colon most cancers mid sixties, had excessive ldl cholesterol, diabetes, and HTN Sister 15- Bronchial asthma Brother 26- overweight Paternal uncle- alcholism Denies some other household medical historical past.
• Mom: age 50, hypertension, elevated ldl cholesterol • Father: deceased in automotive accident one yr in the past at age 58, hypertension, excessive ldl cholesterol, and sort 2 diabetes • Brother (Michael, 25): chubby • Sister (Britney, 14): bronchial asthma • Maternal grandmother: died at age 73 of a stroke, historical past of hypertension, excessive ldl cholesterol • Maternal grandfather: died at age 78 of a stroke, historical past of hypertension, excessive ldl cholesterol • Paternal grandmother: nonetheless dwelling, age 82, hypertension • Paternal grandfather: died at age 65 of colon most cancers, historical past of sort 2 diabetes • Paternal uncle: alcoholism • Unfavorable for psychological sickness, different cancers, sudden dying, kidney illness, sickle cell anemia, thyroid issues
Social Historical past
Pt simply graduated faculty with an accounting diploma, by no means married, no kids, pt in a relationship with a male, pt denies smoking or drug use, occasional alcohol with associates. Pt likes to learn, presently lives at residence along with her mom and sister however has plans to maneuver out subsequent month.
By no means married, no kids. … CONT
Psychological Health Historical past
Pt denies any … CONT
Experiences decreased stress and improved coping skills …. CONT
Assessment of Techniques – Common
Common: no weak point, fatigue or fevers. Constructive weight lack of 10 kilos. Pores and skin: no rashes, lesions, dry pores and skin, ithcing or clor modifications, no dandruff, or modifications in nails. HEENT: … CONT
No latest or frequent sickness, … CONT
CLICK HERE TO ORDER NR 509 Tina Jones Comprehensive Health Assessment
HEENT
Scholar Documentation Mannequin Documentation
Subjective
Denies complications, eye ache or points, no sinus strain, ,,, CONT
Experiences no present headache and no historical past of head damage or acute visible modifications. … CONT
Goal
No apparent accidents or bruising. Head is normocephalic. ,,, CONT
Head is normocephalic, atraumatic. Bilateral eyes with equal hair distribution on lashes and eyebrows, … CONT
NR 509 Tina Jones Comprehensive Health Assessment
Respiratory
Scholar Documentation Mannequin Documentation
Subjective
Pt denies shortness of breath, tough respiration, wheezing or cough. Pt has historical past of bronchial asthma. Denies sinus strain or rhinnorhea.
Experiences no shortness of breath, wheezing, chest ache, dyspnea, or cough.
Goal
Peak movement x3: … CONT
Chest is symmetric … CONT
NR 509 Tina Jones Comprehensive Health Assessment
Cardiovascular
Scholar Documentation Mannequin Documentation
Subjective
Pt denies chest ache, palpitaitons, or edema. No historical past of anemia or simple bruising.
Experiences no palpitations, tachycardia, simple bruising, or edema.
Goal
S1, S2 heard with regular charge and rythm, no murmurs or gallops famous on auscultation. … CONT
Coronary heart charge is common, S1, S2, with out murmurs, gallops, or rubs. … CONT
NR 509 Tina Jones Comprehensive Health Assessment
Belly
Scholar Documentation Mannequin Documentation
Subjective
Pt denies any nausea, vomiting, diarrhea, constipation, belly ache or discomfort. … CONT
Gastrointestinal: … CONT.
Goal
Stomach no seen brusing or lesions, protuberant,… CONT
Stomach protuberant,… CONT
Musculoskeletal
Scholar Documentation Mannequin Documentation
Subjective
Pt denies no joint or muscle ache, no weak point or edema.
Experiences no muscle ache, joint ache, muscle weak point, or swelling.
Goal
No apparent accidents … CONT
Power 5/5… CONT
NR 509 Tina Jones Comprehensive Health Assessment
Neurological
Scholar Documentation Mannequin Documentation
Subjective
Pt denies any numbness or tingling sensations, … CONT
Experiences no dizziness, … CONT
Goal
Graphesthesia, stereognosis intact. Pt alert and oriented x four. … CONT
Regular graphesthesia, … CONT
Pores and skin, Hair & Nails
Scholar Documentation Mannequin Documentation
Subjective
Pt denies rashes, … CONT
Experiences improved pimples attributable to … CONT
Goal
No apparent accidents, lacerations, rashes, dandruff, or bruising. Pt’s hair effectively groomed with even hair distribution. No nail deformities famous in all extremities, clear with no ridges. Extreme hair progress on umbilicus, skinny hair progress on higher lip.
Scattered pustules on face and facial hair on higher lip, acanthosis nigricans on posterior neck. Nails fre
NR 509 Tina Jones Comprehensive Health Assessment RUBRIC
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Shadow Health Bodily Assessment Rubric
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Standards Scores Pts
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This criterion is linked to a Studying OutcomeSubjective Knowledge, Group, Communication, and Abstract (DCE Rating or transcript) _9172
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threshold: pts
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25.zero to >21.zero pts
Above Common- DCE Rating higher than or equal to 93; Comprehensive introduction with expectations of examination verbalized; questions worded in a non-judgmental approach; skilled language exercised; questions well-organized; applicable closing with abstract of findings verbalized to affected person.
_7235
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21.zero to >10.zero pts
Common- DCE Rating higher than or equal to 86-92; Ample introduction; some questions worded in a non-judgmental approach; skilled language principally exercised; questions usually organized; considerably full closing.
_9258
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10.zero to >zero.zero pts
Beneath Common- DCE Rating higher than or equal to 80-85; Incomplete introduction; many questions worded in a judgmental approach; some skilled language exercised; questions considerably organized; incomplete closing.
_2206
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zero.zero to >zero pts
Unsatisfactory- DCE Rating lower than or equal to 79; Introduction lacking; questions worded in a judgmental approach; little skilled language; questions unorganized; closing lacking.
_4625
This space will likely be utilized by the assessor to depart feedback associated to this criterion.
pts
/ 25.zero pts
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This criterion is linked to a Studying OutcomeObjective Knowledge, Bodily Examination, Interpretation of Findings, Assessment, and Documentation _5446
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threshold: pts
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20.zero to >16.zero pts
Above Common- Bodily Assessment documentation consists of all related physique techniques; all pertinent regular and irregular findings recognized; documentation displays skilled language; remedy plan consists of every of the next elements: diagnostics, medicine, schooling, session/referral, and follow-up planning.
_8504
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16.zero to >eight.zero pts
Common- Bodily Assessment documentation lacks ample particulars pertaining to 1 or two related physique techniques; or identifies ≥ 50% of the pertinent regular and irregular findings; or documentation lacks skilled language; or remedy plan lacks one or two elements (diagnostics, medicine, schooling, session/referral, or follow-up planning).
_9311
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eight.zero to >zero.zero pts
Beneath Common- Bodily Assessment documentation lacks ample particulars pertaining to 3 or extra related physique techniques; or identifies < 49% of the pertinent regular and irregular findings; or documentation consists of unprofessional language; or remedy plan lacks three or extra elements (diagnostics, medicine, schooling, session/referral, or follow-up planning).
_1424
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zero.zero to >zero pts
Unsatisfactory- No bodily Assessment documentation or no remedy
