Biology > EXAM > Tina Jones Comprehensive Health Aeeseement Capella University - BIO 100 (All)

Tina Jones Comprehensive Health Aeeseement Capella University - BIO 100

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Documentation / Electronic Health Record  Documentation 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.Student Documentation Model Documentation 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, welldeveloped, 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. [Show More]

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