Comprehensive Assessment Results | Turned In
Advanced Health Assessment - September '17 , NREO81 NRE-662 01A
Return to Assignment
Your Results Lab Pass
Documentation
Vitals
Student Documentation Model Documentation
...
Comprehensive Assessment Results | Turned In
Advanced Health Assessment - September '17 , NREO81 NRE-662 01A
Return to Assignment
Your Results Lab Pass
Documentation
Vitals
Student Documentation Model Documentation
128/82 mm Hg (97.3 MAP)
HP 78
99% SpO2
98.9 degrees F
FVC 3.91 L
FEV1 3.15 L
FEV1/FVC - 0.81
• 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
Able to state name and date of birth that matches
EHR records. Oriented x3.
(For the record, I did stop before starting asking
questions. There should be a lapse in time. I was
documenting)
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 28 year old obese, African American
woman who is clearly able to keep up with her ADLs.
Her hair is braided, her clothes are clean, she seems
to be able to keep up with hygiene. She does not
seem to be in any acute distress.
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.
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Documentation
Plan My Exam
Self-Reflection
Documentation / Electronic Health Record
Student Documentation Model Documentation
Reason for Visit
Ms. Jones is here for a head-to-toe exam for
insurance purposes for her new job.
“I came in because I'm required to have a recent
physical exam for the health insurance at my new
job.”
History of Present Illness
No present illness, does not admit to symptoms and
states she is "doing well, thanks!"
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 th
[Show More]
