Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Student Pre-Survey
Lifespan
Review Questions
Self-Reflection
Document: Provider Notes
Document: Provid
...
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Student Pre-Survey
Lifespan
Review Questions
Self-Reflection
Document: Provider Notes
Document: Provider Notes
Student Documentation Model Documentation
Subjective
HPI: Tina Jones comes to the clinic with the chief
complaint of headaches and neck stiffness. This
occured about five days ago, but the patient was in a
minor "fender bender" a week ago. Tina was the
passenger and she was wearing a seatbelt. She
claims that the accident was at low speed. She did
not seek further care after the EMTs looked her over
and declared that she was okay. However, two days
later, she started to have terrible headaches ad her
stiff neck. She also notes that her neck may be
swollen. Tina did not lose conciousness, not has she
lost conciousness or fainted since. She has been
having a headaches daily for the last five days. The
headaches last "about an hour or two" and she rates
the severity at a 4. She describes the pain as "a dull
ache in the corwn of my head and the back of my
head." She takes Tylenol to manage the pain as
needed. She did not know the dose, but she
"generally takes 2 regular strength pills." She denies
any other symptoms.
Social History: Patient states that she always weras
her seatbelt. She claims that she is a safe driver. Her
father was in an accident, so she takes it seriously.
Patient does not smoke or do drugs.
ROS:
General: patient denies any fatigue or weakness.
Head: patient denies any current headache. patient
HPI: Ms. Jones presents to the clinic complaining of
a headache and neck stiffness that started 2 days
after she was in a minor fender bender. One week
ago she states that she was a restrained passenger
in an accident in a parking lot and estimates the
speed to be approximately 5-10 mph. She and the
driver did not seek emergent care and felt fine after
the accident. Two days later, however, she
developed a bilateral temporal dull ache
accompanied by neck ache. She states that she
feels as though her neck may be slightly swollen as
well. She did not lose consciousness in the accident
and denies changes in level of consciousness since
that time. She states that she gets a headache every
day that lasts approximately 1-2 hours. She
occasionally takes 650 mg of over the counter
Tylenol with relief of the pain. She denies known
associated symptoms.
Review of Systems: General: Denies changes in
weight, fatigue, weakness, fever, chills, and night
sweats. • Head: Denies history of trauma before this
incident. Denies current headache. • Eyes: She does
not wear corrective lenses, but notes that her vision
has been worsening over the past few years, but no
acute changes. She complains of blurry vision after
reading for extended periods. Denies increased
tearing or itching. • Ears: Denies hearing loss,
tinnitus, vertigo, discharge, or earache. •
Nose/Sinuses: Denies rhinorrhea. Denies stuffiness,
sneezing, itching, previous allergy, epistaxis, or sinus
pressure. • Musculoskeletal: Denies muscle
weakness, pain, difficulties with range of motion, joint
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