NURSING > SHADOW HEALTH > Comprehensive Assessment Completed Shadow Health | 8 pages (All)

Comprehensive Assessment Completed Shadow Health | 8 pages

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Health History Student Documentation Model Documentation Identifying Data & Reliability Provides full name and verifies date of birth. Ms. Jones is a pleasant, 28-year-old African American single woman who presents ...

Health History Student Documentation Model Documentation Identifying Data & Reliability Provides full name and verifies date of birth. Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a preemployment 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 Ms. Jones is a pleasant, well-groomed 28 year old AFrican American female wearing glasses to correct nearsightedness, 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 Ms. Jones presents to clinic today for a preemployment physical. "I came in because I'm required to have a recent physical exam for the health insurance at my new job." Overview Transcript Subjective Data Collection Objective Data Collection Documentation Plan My Exam Self-Reflection Documentation / Electronic Health Record History of Present Illness REports no current health issues. Hx of Asthma (Albuterol); Diabetes (Metformin) and Polycystic Ovaria Syndrome (Yaz). Patient rates current health at an 8/10. Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. She needs to obtain a pre-employment physical prior to initiating employment. Today she denies any acute concerns. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. She has no medication side effects at this time. She states that she feels healthy, is taking better care of herself than in the past, and is looking forward to beginning the new job.

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