NR 509 Tina Jones Comprehensive Health Assessment

 Documentation / Electronic Health Record



Student DocumentationModel 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 DocumentationModel Documentation
Identifying Data & ReliabilityMs. 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 beginMs. 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- … CONTAsthma diagnosed at age 2 1/2. … CONT
Health Maintenance Since our last encounter … CONTLast 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 … CONTReports 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: … CONTNo recent or frequent illness, … CONT


Student DocumentationModel Documentation
SubjectiveReports 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. ,,, CONTHead is normocephalic, atraumatic. Bilateral eyes with equal hair distribution on lashes and eyebrows, … CONT


Student DocumentationModel 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: … CONTChest is symmetric … CONT


Student DocumentationModel 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. … CONTHeart rate is regular, S1, S2, without murmurs, gallops, or rubs. … CONT


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


Student DocumentationModel 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 … CONTStrength 5/5… CONT


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

Skin, Hair & Nails

Student DocumentationModel Documentation
Subjective Pt denies rashes, … CONTReports improved acne due to … CONT
ObjectiveScattered 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
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
Delete criterion/ 25.0
This criterion is
linked to a 
Subjective Data, 
and Summary 
(DCE Score or 
transcript) _9172 
view longer 
threshold: ptsnon-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 documentationpts / 20.0pts —
Range threshold: ptslanguage; 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 assignmentpts / 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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