NR 509 Tina Jones Comprehensive Health Assessment

NR 509 Tina Jones Comprehensive Health Assessment

NR 509 Tina Jones Comprehensive Health Assessment

Documentation / Electronic Health Record

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Vitals

Student Documentation Model Documentation
BP 128/82 P 78 RR 15 Temp 37.2 O2 99% Weight 84kg Height 5’6″ BMI 29 BS 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 wtih 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 clininc 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- deeased 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- alcholism 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, ithcing or clor changes, no dandruff, or changes in nails. HEENT: … CONT

No recent or frequent illness, … CONT

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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

NR 509 Tina Jones Comprehensive Health Assessment

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

NR 509 Tina Jones Comprehensive Health Assessment

Cardiovascular

Student Documentation Model Documentation
Subjective

Pt denies chest pain, palpitaitons, 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

NR 509 Tina Jones Comprehensive Health Assessment

Abdominal

Student Documentation Model Documentation
Subjective

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

Gastrointestinal: … CONT.
Objective

Abdomen no visible brusing 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

NR 509 Tina Jones Comprehensive Health Assessment

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

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

NR 509 Tina Jones Comprehensive Health Assessment RUBRIC

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Shadow Health Physical Assessment Rubric

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Shadow Health Physical Assessment Rubric
Criteria Ratings Pts
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This criterion is linked to a Learning OutcomeSubjective Data, Organization, Communication, and Summary (DCE Score or transcript) _9172

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Range

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25.0 to >21.0 pts

Above Average- DCE Score greater than or equal to 93; Comprehensive introduction with expectations of exam verbalized; questions worded in a non-judgmental way; professional language exercised; questions well-organized; appropriate closing with summary of findings verbalized to patient.

_7235

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21.0 to >10.0 pts

Average- DCE Score greater than or equal to 86-92; Adequate introduction; some questions worded in a non-judgmental way; professional language mostly exercised; questions generally organized; somewhat complete closing.

_9258

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10.0 to >0.0 pts

Below Average- DCE Score greater than or equal to 80-85; Incomplete introduction; many questions worded in a judgmental way; some professional language exercised; questions somewhat organized; incomplete closing.

_2206

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0.0 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.

_4625

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pts

/ 25.0 pts

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This criterion is linked to a Learning OutcomeObjective Data, Physical Examination, Interpretation of Findings, Assessment, and Documentation _5446

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20.0 to >16.0 pts

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 of the following components: diagnostics, medication, education, consultation/referral, and follow-up planning.

_8504

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16.0 to >8.0 pts

Average- Physical assessment documentation lacks sufficient details pertaining to one or two relevant body systems; or identifies ≥ 50% of the pertinent normal and abnormal findings; or documentation lacks professional language; or treatment plan lacks one or two components (diagnostics, medication, education, consultation/referral, or follow-up planning).

_9311

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8.0 to >0.0 pts

Below Average- Physical assessment documentation lacks sufficient details pertaining to three or more relevant body systems; or identifies < 49% of the pertinent normal and abnormal findings; or documentation includes unprofessional language; or treatment plan lacks three or more components (diagnostics, medication, education, consultation/referral, or follow-up planning).

_1424

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0.0 to >0 pts

Unsatisfactory- No physical assessment documentation or no treatment plan.

_224

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This criterion is linked to a Learning OutcomeSelf-Reflection _3128

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5.0 to >3.0 pts

Above Average- Responds to three of the three reflection post questions; and provides analysis of performance; and reflection posts written using professional language; and reflection posts demonstrate insight.

_7104

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3.0 to >2.0 pts

Average- Responds to two of the three reflection post questions; or provides limited self-analysis of performance; or reflection posts are somewhat unclear related to the assignment and the student’s experience; or reflection posts lack insight.

_9169

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2.0 to >0.0 pts

Below Average- Responds to one of the three reflection post questions; or does not provide self-analysis of performance; or reflections are not related to the assignment and the student’s experience; or does not provide insight

_2706

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0.0 to >0 pts

Unsatisfactory- No reflection posts for the assignment.

_6746

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/ 5.0 pts

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Total Points: 50.0 out of 50.0
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