NR 509 Tina Jones Comprehensive Health Assessment
Documentation / Electronic Health Record
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 single woman who presents for a pre-employment physical. She is the primary source of history. Ms. |
| 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, and maintain eye contact throughout the exam. | 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 iswell-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 IllnessPt presents to the clinic for an employment physical that she will begin | Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. …. CONT |
| in two weeks. Pt denies any medical issues or concerns. … CONT | |
| Medications Flovent 110 mcg 2 puffs BID Albuterol 90 mcg 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 our last encounter … CONT | Last Pap smear 4 months ago. Last eye exam was three months ago. Last dental exam was 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 HistoryPt just graduated college with an accounting degree, never married, no children, pt in a relationship with a male, | Never married, no children. … CONT |
| 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. | |
| 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 | Reports no current headache and no history of head injury or acute visual changes. … CONT |
| Denies headaches, eye pain or issues, no sinus pressure, ,,, 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 a history of asthma. Denies sinus pressure or rhinorrhea. | 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 rhythm, 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 | Gastrointestinal: … CONT. |
| Pt denies any nausea, vomiting, diarrhea, constipation, abdominal pain or discomfort. … 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 |
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 |
Skin, Hair & Nails
| Student Documentation | Model Documentation |
| Subjective Pt denies rashes, … CONT | Reports improved acne due to … CONT |
| 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. Pt’s hair iswell-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 | |||||
| Criteria | Ratings | Pts | |||
| Edit criterion | Edit rating Delete rating25.0 to >21.0pts Above Average- DCE Score greater than or equal to 93; Comprehensive introduction with expectations of exam verbalized; questions worded in a | Edit rating Delete rating21.0 to >10.0pts Average- DCE Score greater than or equal to 86-92;Adequate introduction; some questions worded in a non-judgment al way; professional language | Edit rating Delete rating10.0 to >0.0pts Below Average- DCE Score greater than or equal to 80-85;Incomplete introduction; many questions worded in a judgmental way; some | Edit rating Delete rating0.0 to >0 pts Unsatisfactory- DCE Score less than or equal to 79; Introduction missing; questions worded in a judgmental way; little professional language; questions unorganized; closing missing. | pts |
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| Delete criterion | / 25.0 | ||||
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| This criterion is | — | ||||
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| Learning | |||||
| Outcome | |||||
| Subjective Data, | |||||
| Organization, | |||||
| Communication, | |||||
| and Summary | |||||
| (DCE Score or | |||||
| transcript) _9172 | |||||
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| threshold: pts | non-judgment mostly professional _4625 al way; exercised; language professional questions exercised;language generally questions exercised; organized; somewhat questions somewhat organized; well-organized complete incomplete; appropriate closing. closing. closing withsummary of _9258 _2206findings verbalized to patients._7235 This area will be used by the assessor to leave comments related to this criterion. | |
| Edit criterion description Delete criterion rowThis criterion is linked to a Learning Outcome Objective Data, Physical Examination, Interpretation of Findings, Assessment, and Documentation_5446 view longer description | Edit rating Edit rating Edit rating Edit rating Delete rating Delete rating Delete rating Deleterating20.0 to >16.0 16.0 to >8.0 8.0 to >0.0 ptspts pts 0.0 to >0Below Average- pts Above Average- Average- PhysicalPhysical Physical assessment Unsatisfactory assessment assessment documentation ory- No documentation documentation lacks sufficient physical includes all n lacks details assessment relevant body sufficient pertaining to documentation systems; all details three or more ion or no pertinent pertaining to relevant body treatment normal and one or two systems; or plan. abnormal relevant body identifies < 49%findings systems; or of the pertinent _224identified; identifies ≥ normal and documentation 50% of the abnormal reflects pertinent findings; or professional normal and documentation | pts / 20.0pts — |
| Range threshold: pts | language; abnormal includes treatment plan findings; or unprofessional includes each documentation language; or of the following n lacks treatment plan components: professional lacks three or diagnostics, language; or more medication, treatment components education, plan lacks one (diagnostics, consultation/re or two medication, feral, and components education,follow-up (diagnostics, consultation/ref planning. medication, erral, oreducation, follow-up_8504 consultation/r planning). eferral, orfollow-up _1424planning). _9311 This area will be used by the assessor to leave comments related to this criterion. | |
| Edit criterion description Delete criterion rowThis criterion is linked to a Learning OutcomeSelf-Reflection_3128 view longer descriptionRange threshold: pts | Edit rating Edit rating Edit rating Edit rating Delete rating Delete rating Delete rating Delete rating5.0 to >3.0 pts 3.0 to >2.0 2.0 to >0.0 pts 0.0 to >0 pts ptsAbove Below Average- UnsatisfactoryAverage- Average- Responds to – No reflection Responds to Responds to one of the three posts for the three of the two of the reflection post assignment. three three questions; orreflection post reflection does not _6746questions; post provideand provides questions; or self-analysis of analysis of provides performance; or performance; limited reflections are and reflection self-analysis not related to posts written of the assignment | pts / 5.0pts — |
| using performance; and the professional or reflection student’s language; and posts are experience; or reflection somewhat does not posts unclear provide insight demonstrate related to theinsight. assignment _2706and the_7104 student’s experience; or reflection posts lack insight._9169 This area will be used by the assessor to leave comments related to this criterion. | |||
| Edit criterion description Delete criterion rowThis criterion is linked to a Learning Outcome Description of criterionview longer descriptionRange threshold: 5 pts | Edit rating Delete rating Edit rating Deleterating5to >0 pts0 to >0 ptsFull MarksNo Marksblankblank_2 This area will be used by the assessor to leave comments related to this criterion. | pts / 5 pts — | |
| Total Points: 50.0 out of 50.0 | |||
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