Documentation / Electronic Health Record
Documentation: Provider Notes
Student Documentation Model Documentation
Subjective
pee a lot
21 y.o. F c/o of buring urination and lower abdominal pain that started
3 days a
...
Documentation / Electronic Health Record
Documentation: Provider Notes
Student Documentation Model Documentation
Subjective
pee a lot
21 y.o. F c/o of buring urination and lower abdominal pain that started
3 days ago. Buring urination and lower abdominal pain every time she
urinates. Pt stated stinging, burning pain at the urethra seven out of
10 and lower abdomen cramps during urination. Urine described as a
little dark, brown, cloudy, and foul-smelling. Increased urination
frequency. Urination makes the pain worse. Drinking less water to
prevent frequent urination makes it better. Pt has been taking
cranberry supplement 3 days ago but symptoms have not changed.
Denies incontinence. Pt has seasonal allergies, penicillin allergies,
and resistant to sulfamethoxasole/trimethoprim. Reactions to
penicillin include red, ithchy rash, sick to her stomach, and vomiting.
Pt has no existing health conditions. She is currently taking loratdine
10 mg tab once a day for allergies and ethinyl estradiol and
norgestimate 28pack pill once every morning for 3 years.
She is sexually active with 1 partner and had sex 4 days ago without
urinating after sex. Pt uses birth control and partner uses condom and
spermicide as contraceptives. Her last menstrual period was 2.5
weeks ago and is regular. She denies using recreational drugs,
nicotine, and tobacco. She had tried weed once and drinks wine or
beer 1-2 glasses a week. She denies fever, night sweats, chills,
fatigue, and weight loss. She has not been sleeping well.
(No Model Documentation Provided)
Objective
(No Documentation Made) (No Model Documentation Provided)
Your Results Turn In (/assignment_attempts/7379321/choos
Reopen (/assignment_attempts/7379321/reopen
Lab Pass (/assignment_attempts/7379321/lab_pass.p
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Debrief
Medication Selection
Patient Teaching
Prescription Writing
Documentation: Provider Notes
Comments Support
This study source was downloaded by 100000831988016 from CourseHero.com on 05-07-2022 05:35:40 GMT -05:00
https://www.coursehero.com/file/65678954/Focused-Exam-UTI-with-Antibiotic-Sensitivity-Documentationpdf/
7/25/2020 Focused Exam: UTI with Antibiotic Sensitivity | Completed | Shadow Health
https://app.shadowhealth.com/assignment_attempts/7379321 2/2
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