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Shadow Health Comprehensive Tina Jones Documentation/ Electronic Health Record

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Documentation / Electronic Health Record  Documentation Vitals Student Documentation Model Documentation BP: 128/82 Pulse: 78 Respiratory Rate: 15 SpO2: 99% Temperature: 37.2 C • Height: 17... 0 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 28 years old African American single woman, alert and oriented x 3. She is the primary source of the history. 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. General Survey Ms jones speech is clear and coherent. She appears well nourished, developed, and dressed. No distress noted. She maintain eye contact throughout the interview. 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 Ms Jones presents to clinic "I'm required to have a recent physical exam for the health insurance at my new job" “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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