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NR_509_Neurological_Documentation_Shadow - Chamberlain College of Nursing | Documentation / Electronic Health Record

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NR_509_Neurological_Documentation_Shadow - Chamberlain College of Nursing Documentation / Electronic Health Record Neurological Physical Assessment Assignment Results | Turned In Advanced Health Assessment - Chamberlain, NR509-October-2018 Document: Provider Notes Document: Provider Notes Student Documentation Model Documentation HPI: Ms. Jones presents to the clinic complaining of a headache and neck stiffness that started 2 days after she was in a minor fender bender. One week ago she states that she was a restrained passenger in an accident in a parking lot and estimates the speed to be approximately 5-10 mph. She and the driver did not seek emergent care and felt fine after the accident. Two days later, however, she developed a bilateral temporal dull ache accompanied by neck ache. She states that she feels as though her neck may be slightly swollen as well. She did not lose consciousness in the accident and denies changes in level of consciousness since that time. She states that she gets a headache every day that lasts approximately 1-2 hours. She occasionally takes 650 mg of over the counter Tylenol with relief of the pain. She denies know - - - - - - - Student Documentation Model Documentation Objective denies any trauma before the car accident. Eyes: Patient does not wear corrective lenses. Patient states that her vision becomes blurry when she reads for extended periods. States that her vision is worsening. Patient denies eye pain or itching. Ear: patient denies any ear pain or ringing in the ears. Nose: Patient denies any congestion and sneezing. Patient does not an allergy to cats and mold that can cause sneezes. Musculoskeletal: Patient denies any muscle pain or weakness anywhere other than her neck. Patient notes possible swelling in the neck, but nowhere else. Neurologic: Patient denies any weakness or dizziness. Patient denies fainting. Patient denies any tingling or tremors. Patient notes no changes in bladder or bowels. Patient denies any changes in concentration or sleep. instability, or swelling. • Neurologic: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures. Denies bowel or bladder dysfunction. Denies change

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