*NURSING > SHADOW HEALTH > NR-509 Advanced Physical Assessment-Shadow Health Tina Jones Documentation-EHR (All)

NR-509 Advanced Physical Assessment-Shadow Health Tina Jones Documentation-EHR

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ocument: Provider Notes Student Documentation Model Documentation Health History Tips and Tricks Lifespan Self-Reflection Identifying Data & Reliability Ms. Tina Jones 28 year old , African Amer... ican, single who presents to the clinic with concerns of her recent right foot injury. Ms. Jones is pleasant and good historian. Ms. Jones is a pleasant, 28-year-old obese African American s woman who presents to establish care and with a recent right f injury. She is the primary source of the history. Ms. Jones offer information freely and without contradiction. Speech is clear an coherent. She maintains eye contact throughout the interview. General Survey Ms. Jones is alert and oriented, no apparent distress, properly groomed. Ms. Jones is alert and oriented, seated upright on the examina table, and is in no apparent distress. She is well-nourished, we developed, and dressed appropriately with good hygiene. Chief Complaint Patient reports that she sustained a scraped at the plantar surface of her foot. The wound is draining with pus, no fouly smell but the pain is bothering her, and the pain got worse of the last 2 days. Patient states that the "pain is killing me". “I got this scrape on my foot a while ago, and I thought it would up on its own, but now it's looking pretty nasty. And the pain is killing me!” [Show More]

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