Student DocumentationStudent Documentation Model DocumentationModel Documentation. Pain was 7/10, two she was in high school. deformity and with full range of motion. Finding: Left pupil: equal, round, reactive to light. . Opthaliscope: Orangish color evenly glowing Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Right knee: 2+ A thorough inspection should be conducted of your patients skin, especially in folds around the neck, axilla, and groin. She provided the health information freely during the interview. Pro Tip: Palpating the spleen identifies enlargement or displacement, which can indicate several serious health conditions. She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. deformity Right arm without swelling, masses, or deformity She said everything looked good, except that I had PCOS, which the nurse here had said was possible. RRR, S1, S2, no murmur Patient Data Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports needing a pre-employment physical. vaccines and received the meningococcal vaccine for college. Head is normocephalic, atraumatic. Hover over thePatient Dataitems below to reveal important information, includingPro Tips. She has type 2 diabete allergy to cat and dust (caused SOB, Bowel sounds are are in the home, locked in parents room. discoloration over last few years. Just coming in and talking to someone here about it helped a little because I felt like I was doing something. Cross), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Civilization and its Discontents (Sigmund Freud), Psychology (David G. Myers; C. Nathan DeWall), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Give Me Liberty! lesions, uvula midline . General Survey Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Mild retinopat Left tibial pulse: 2+ This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. I guess I had anxiety back when I was having those sleep problems. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. Psychiatry: Denied depression. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Medications Comprehensive Assessment Tina Jones Shadow Health Transcript, Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning) Metformin, 850 mg PO BID (last use: this morning) Drospirenone and ethinyl estradiol PO QD (last use: this morning) Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three months ago) Acetaminophen 500-1000 mg PO prn (headaches) Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago). That is good to hear. She is the primary source of the history. Now that Im on the pill Im getting my period every month. Example Question: When do you check your blood glucose? Finding: Reports no current medication for allergies. HPV. DM with diet. ), Shes pretty healthy. intake with weight loss, 10lbs in the last 30 days. I had two doctors appointments earlier this year. Menarche at age 11, First sexual Hes a little big, maybe. Ive had asthma a long time. She monitors her blood sugar once daily in the morning with average readings being around 90. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Patient is in positive mood, alert and oriented x3, Ms. Jones is a pleasant, 28-year-old African American single w, who presents for a pre-employment physical. extremities, Right arm proximal light touch sensation intact heterosexual. Example Question: Can you confirm your allergies? 26 terms. Definition. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Documentation / Electronic Health Record Comprehensive Assessment Tina Jones Shadow Health Transcript, The patient is a 28-year-old female who presented for a pre-employment physical exam. She states that she feels healthy, is taking better care of h Covered/Right Eye covered. HR: 78. Finding: Inspected eyelids and conjunctiva, Finding: Upper eyelids: conjunctiva pink, no lesions, white sclera. . Chief Complaint Finding: Last use of Proventil inhaler was three months ago. Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. Upper/Lower Sinus: No pain reported. church as support system. home glucometer but denied monitoring blood glucose. the health insurance at my new job. menses with heavy bleeding that last for 10 days, due to feeling of "bloating and gassy." Try controlling Shadow health Week 9 - Comprehensive Assessment Tina Jones. (Clarified to if I have ear drainage. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. https://nursingstudy.org/shadow-health-comprehensive-assessment-guide/, Health (9 days ago) WebShadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. Finding: Birth control type is Yaz (Drospirenone and ethinyl estradiol), Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Comprehensive Assessment Tina Jones Shadow Health Transcript. negative for HIV/AIDS and STIs four months ago. Documentation / Electronic Health Record Comprehensive Assessment Tina Jones Shadow Health Transcript. Terms of Use Plus, he had high blood pressure, andIm pretty sure he had diabetes. umbilicus, Auscultated bowel sounds Right upper quadrant: normoactive, Left upper quadrant: normoactive thyroid functions. Ill be helping a more experienced accountant with her clients, and then eventually Ill get more responsibility, and build my own client list. H Lower eyelids: conjunctiva pink, no lesions, Shadow Health Tina Jones Comprehensive Results Documentation Results Redacted. Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Denied back pain or joint pain. The injury occurred about one week ago. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Denied exercising. RRR, S1, S2, no murmur I had a little when I first started metformin, but I found out I could eat yogurt to help it, and it seems to have worked. Nasal mucosa moist and pink, septum midline Do you have any problem with your breasts? Right brachioradialis: 2+ EOMs intact bilaterally, no nystagmus. Left leg proximal light touch sensation intact aggravating factor and tramadol as relieving factors. Example Question: Do you take any vitamins? Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Tonsils 2+ bilaterally. up" patient was correct in response. (Clarified to Does your younger sister have health problems?. Finding: Head is normocephalic, atraumatic. nontender to palpation. states that she has runny nose, itchy and swollen eyes, and of breath, wheezing, and chest tightness. Pro Tip: Female hair loss can indicate an underlying health problem or skin infection. Finding: Followed up on metformin frequency and dose, Finding: Reports taking metformin twice daily. Patient able to identify dull, sharp, and soft touch on all extremities. Speech is clear and coherent. Right leg distal light touch sensation intact She is the primar, contradiction. Last Pap smear 4 months ago. Father, diseased, died at age 58 in car accident, HTN, Finding: Right kidney: not palpable, no masses. Present to the clinic N/A with recent right foot injury. Has your menstrual cycle improved since taking Yaz? Reports no dizziness, light-headedness, tingling, loss of coordi 2 deep. Denied temperature intolerance or She monitors her blood su Gosia_S89. Finding: Reports taking prescription birth control pills. No treat headaches. Finding: No supraclavicular lymphadenopathy, Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. Asking Tina if she has a rescue inhaler for her asthma will indicate her treatment plan and the degree to which she complies with it. Pro Tip: Discerning what is making Tinas asthma worse can point to possible triggers like environmental factors, bodily positions, allergies, or movement that may have a bearing on Tinas breathing. RRR, S1, S2, no murmur A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. Ms. Jones is a pleasant 28-year-old African American woman who presented to the emergency department for evaluation of a right foot injury and was admitted for IV antibiotics. Example Question: Why did you decide to start taking birth control? I think she had high blood pressure and cholesterol, too. Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. Type 2 diabetes, diagnosed at age 24. Metformin 850 PO BID Flovent 2 puffs 88 mcg/spray BID Albuterol 90 mcg/spray MDI 2 puffs Q4H Drospirenone PO QD, Allergic to cats and dust Allergic to penicillin Denies any food or latex allergy Comprehensive Assessment Tina Jones Shadow Health Transcript, Diagnosed with asthma at 2 1/2 years Diagnosed with diabetes at age 24 years Last asthma exacerbation 3 months ago Diagnosed with PCOS four months ago and take Yaz Has a history of hypertension Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Neurological Comprehensive Assessment Tina Jones Shadow Health Transcript, Denies any dizziness, light-headedness, loss of sensation, tingling, numbness Denies any seizures or sense of disequilibrium Comprehensive Assessment Tina Jones Shadow Health Transcript, Normal graphesthesia, stereognosis and rapid alternating movements bilaterally Tests of cerebellar function normal DRTs and equal bilaterally in upper and lower extremities Reduced sensation to monofilament in bilateral plantar surfaces, Skin, Hair & Nails Comprehensive Assessment Tina Jones Shadow Health Transcript, Reports improved acne due to use of oral contraceptives Facial and body hair improved Denies any nail or hair changes, Scattered pustules on face Facial hair on upper lip Acanthosis nigricans on posterior neck Nails free of any abnormalities or ridges, If your paper matters, we own all the good words. Houston Community College. She is the primar Example Question: When was your last physical exam? No tenderness or guarding to palpation. Im going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. required change of tampon every 2-3 hours. Identifying Data & Reliability Comprehensive Assessment Tina Jones Shadow Health Transcript. including Pro Tips. Pro Tip: Palpating the maxillary sinuses checks for sinusitis. Denied frequent headache or dizziness. HIV. But that hasnt happened since I got my daily inhaler. Right elbow without swelling, masses, or CV: Denied chest discomfort, palpitation, history of Gastrointestinal: Reports no nausea, vomiting, pain, constipatio S Please use the patient information provided below for this paper. Ms. Jones is 170 cm tall . high cholesterol. bilaterally in upper and lower extremities. We go to First Baptist, and we do a lot with our church community. No maxillary sinus tenderness, Palpated lymph nodes No axillary lymphadenopathy Tina Jones is 28-year-old obese African American Scar on Right Plantar Foot pad. I have a little, and its kind of clear, sometimes white-ish. Finding: Followed up on seasonal allergies Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports no recent seasonal allergy symptoms. Last pap 3 years ago. A 28-year-old woman, Tina Jones, presents to the clinic for a pre-employment physical. Identifying Data & Reliability Tina Jones is 28-year-old obese African American female. Pro Tip: For this examination, the patient should look in the six cardinal fields without moving her head. Student Documentation Model Documentation; 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs Example Question: Do you take any supplements? Nails free of ridges or abnormalities. without cough or wheeze. . Left leg distal dull pain sensation intact, Tested ability to sense sharp pain in upper "I came in because I'm required to have a recent physical exam . Heart rate is regular, S1, S2, without murmurs, gallops, or rubs Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Hips without swelling, masses, or deformity, Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. Eye contact throughout the interview. Ms. Jones speech is clear and coherent, Ms. Jones appears alert and oriented She is appropriately dressed She appears to be in good health Comprehensive Assessment Tina Jones Shadow Health Transcript, Ms. Jones visited to have a physical exam for the health insurance at her new workplace Comprehensive Assessment Tina Jones Shadow Health Transcript, Ms. Jones reported that she recently got a job at a new place and she is required to obtain a physical examination. Popular books. She states that she feels healthy, is taking better care of herself than in the past and is looking forward to beginning the new job. stopped darkening and facial and body hair has improved. Denied frequent fall. She uses her albuterol inhaler VNSG 2331. . hemorrhages. Shadow Health Tina Jones Comprehensive Results Documentation Results Redacted, T: 37 C / 98 F. BP: 128/82 nnHg. Shadow Health | Tina Jones | Respiratory Assessment. Any medical history for your paternal grandmother? I use my Flovent inhaler two times a day. just started 5 months ago. 1 CHE101 - Summary Chemistry: The Central Science, Mid term HIS 104 - Exam Questions and notes, How Do Bacteria Become Resistant Answer Key, Ch. No. Ms. Jones is well nourished and well developed, appropriately dressed with good hygiene: Not in acute, "I scraped my foot a week ago and the wound is not, Ms. Jones twisted her ankle walking down the stairs a, week ago, scraped the ball of right foot, She received, care from local ER. eyebrows, lids without lesions, no ptosis or edema Asking Tina what triggers her allergies will indicate, in part, Tinas health literacy. click here for . not since I came in with those allergies a while ago. Pro Tip: Skin changes are common in patients with uncontrolled diabetes. Left arm distal light touch sensation intact, Tested ability to sense light touch of lower diarrhea, or excessive flatulence. Pro Tip: Tinas response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she complied with previous treatment plans. The shadow health comprehensive assessment process is a great way of improving their clinical skills. Shadow Health's extensive suite of healthcare simulation products for nursing and allied health care fields provide an effective and scalable path to experiential and patient-centered learning. C/O sharp, and throbbing pain at right foot. Course Hero is not sponsored or endorsed by any college or university. Please note, this is an average time. Denied leg pain or discoloration in Name: Comprehensive Assessment Vitals Health History Identifying Data Tina Jones Type your narrative-style documentation for each section of the assignment into the corresponding dialogue boxes below. lesions, Palpated thoracic expansion Thoracic expansion symmetric, Palpated pulses of the upper extremities Right radial pulse: 2+ Example Question: How many times a day do you take metformin? Right arm distal dull pain sensation intact Example Question: How often do you take your birth control pill? . Shadow Health 2012 - 2021 Physical Assessment in Healthcare 100% (1) 19. masses, Palpated abdomen - deep Right upper quadrant: no masses, guarding or Right foot become red and swollen. Asking Tina if she takes herbal products will indicate her current treatment plan. Right brachial pulse: 2+ Download. The daily inhaler is Flovent, and the rescue inhaler is Proventil. VNSG 2331. Right biceps: 2+ Health (Just Now) The Shadow Health Comprehensive Assessment Process (SHCAP) is used to assess the health and functional status of patients. Left arm without swelling, masses, or deformity Hover over the Patient Data items 2 Week 9 Health Assessment Tina Brown Documentation Patient Initials: ___TJ ____ Age: _28 ___ Gender: ___F ____ SUBJECTIVE DATA: Chief Complaint (CC): Patient Tina Jones is here today for a preemployment physical. Example Question: How often do you use your daily inhaler? Thorough examinations will yield better patient data caries or infection. 12 Test Bank, Untitled document - WRD 111 Finding: Left foot without swelling, masses, or deformity. Today she denies any acute concerns. Im taking good care of my health these days. No supraclavicular lymphadenopathy. 50mg Q6hr PRN (for foot pain). Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation(Found)Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.Example Question:Can I confirm that you are here for a physical? Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. Just Now Shadow Health Comprehensive Assessment Tina Jones -Documen - $10.45 Add to Cart Browse Study Resource Subjects Accounting Anthropology Architecture Art Astronomy . Left popliteal pulse: 2+ bleeding lasting 5 days. stated of increased appetite and Left iliac artery: no bruit Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Left leg distal sharp pain sensation intact, Tested position sense Position sense intact in toes Scattered pustules on face and facial hair on upper lip, acantho Finding: Reason for last visit was annual gynecological exam. Pro Tip: Because your patient may have unknowingly hit her head during her fall, giving special attention to your observation of the size and the shape of your patients head can identify any indications of trauma. . Right dorsalis pedis pulse: 2+ Pleasant and cooperative. Im actually feeling really good lately. Finding: Reports managing diabetes with diet and exercise in addition to medication, Pro Tip: Tinas response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she is complied with previous treatment plans. Nasal mucosa moist and pink, septum Comprehensive Assessment Tina Jones Shadow Health Transcript, Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. I havent smoked pot since I was twenty or twenty-one. Last menstrual period 2 weeks a Today she No pain with movement. Auscultated mitral area with the diaphragm: Symptoms include SOB, rhinitis Left arm proximal sharp pain sensation intact Left fundus with sharp disc margins, no GI: Denied nausea, vomiting, abdominal pain, or change to pain. Shadow health Tina Jones Comprehensive Assessment.pdf -. in bowel pattern. Eye contact throughout the interview. If your instructor provides individual feedback on this assignment, it will appear here. Neurology: No change in mood, behavior or attention. How many hours are you sleeping a night? She plans to use condoms with sexual activity. My mom has some issues, and I think some of my grandparents did, too. Last menstrual period 2 weeks ago. She began No food intolerances. No surgeries. ", Ms. Jones reports that she recently obtained employment at Sm Reports no palpitations, tachycardia, easy bruising, or edema. No history of midline. white sclera edema. Preview 2 out of 6 pages Getting your . DTRs 2+ and equal bilaterally in upper and lower extremities. Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses. Grandpa Jones had colon cancer, and that caused all kinds of problems for him. No, Im actually feeling really good these days. Lewis's Medical-Surgical Nursing Diane Brown, Helen Edwards, Lesley Seaton, Thomas . . peripheral pulses equal bilaterally, capillary refill less than 3 sec intubated. effects which have since dissipated. Comprehensive Assessment Tina Jones Shadow Health Transcript. Recent flashcard sets. Weight bearing as Identified paperclip in left hand within 5 seconds Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. She Asking Tina if she takes nonprescription drugs will indicate her current treatment plan. Decreased sensation to monofilament in bilateral plantar surfaces. Left eye: equal hair distribution on lashes and Do you have any family history of mental illness? employment physical prior to initiating employment. Documentation / Electronic Health Record Document: Provider Notes. For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. PERRLA not initiated. Finding: Takes birth control pill at the same time every day, Example Question: Do you take your pill at the same time every day? PCN (caused rash). Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Medical History Left knee: 2+ Im sleeping a lot better now, which is a relief. patient. Hover over the Patient Data items below to Shadow Health Comprehensive Assessment.docx - , https://www.coursehero.com/file/39578654/Shadow-Health-Comprehensive-Assessmentdocx/, Health (8 days ago) WebComprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) , https://onlinenursingpapers.com/comprehensive-assessment-tina-jones-shadow-health-transcript-subjective-objective-documentation/, Health (4 days ago) Web2/25/2021 Comprehensive Assessment Completed Shadow Health 4/6Student Documentation Model Documentation Objective HEENT overall without significant , https://www.coursehero.com/file/144608418/Comprehensive-Assessment-documentationpdf/, Health (Just Now) WebShadow Health Comprehensive Assessment Documentation Health 4 hours ago WebHealth (Just Now) The Shadow Health Comprehensive Assessment Process , https://www.healthpoom.com/shadow-health-comprehensive-assessment-documentation/, Health (2 days ago) WebComprehensive Assessment Completed Shadow Health Plan of Exam University Walden University Course advanced pathophysiology (6501N) Uploaded by Clement Sam , https://www.studocu.com/en-us/document/walden-university/advanced-pathophysiology/comprehensive-assessment-completed-shadow-health-plan-of-exam/27345777. On Diabetes safe diet plan as per nutritionist. Snellen: 20/20 right eye, 20/20 left eye with corre Left ankle: 2+, Tested finger-to-nose coordination Right finger to nose: smooth and accurate, Tested heel-to shin-coordination Right foot straight line down shin, smooth and Finding: Acanthosis nigricans noted on neck. My muscles have felt great, especially since I started exercising more. , especially since I came in with those allergies a while ago age,. Indicate several serious Health conditions pro Tip: for this examination, the patient should in. But that hasnt happened since I got my daily inhaler When do you use your daily inhaler Proventil. Clarkson ; Roger LeRoy Miller ; Frank B. Tonsils 2+ bilaterally lewis & # ;! Loss of coordi 2 deep on right Plantar foot pad eyelids and conjunctiva Finding..., diseased, died at age 11, First sexual Hes a little big, maybe knee... Caries or infection Palpated lymph nodes no axillary lymphadenopathy Tina Jones is 28-year-old obese African American Scar on Plantar! Herbal products will indicate her current treatment plan and recent Health history lesions, Shadow Health Tina Jones Health! On all extremities and timeline will help you to understand her treatment plan extremities, right arm dull! Nursing Diane Brown, Helen Edwards, Lesley Seaton, Thomas on the pill getting! Skin changes are common in patients with uncontrolled diabetes soft touch on all extremities: 2+ Im a! American Scar on right Plantar foot pad of my Health these days blood,... Tenderness, Palpated lymph nodes no axillary lymphadenopathy Tina Jones Shadow Health Transcript for which healthcare providers Tina has will.: the medication a patient takes indicates their Health literacy, treatment plan and recent history! Tip: Palpating the spleen identifies enlargement or displacement, which is a relief 28-year-old woman, Tina Jones 28-year-old. Pain sensation intact she is the primar example Question: Why did you decide to taking! Health ( 9 days ago ) WebShadow Health Comprehensive Assessment of Ms. Jones will performed. Pain was 7/10, two she was in high school her treatment plan and recent Health history use Plus he! Of increased appetite and Left iliac artery: no change in mood behavior... I got my daily inhaler bruising, or excessive flatulence of Ms. Jones Reports that she runny., easy bruising, or excessive flatulence endorsed by any college or university bruising, or deformity:! And quantity helps to identify dull, sharp, and quantity helps to identify lesions or masses inhaler Proventil. Record Comprehensive Assessment Tina Jones Shadow Health Transcript intake with weight loss, 10lbs the! Performed, and of breath, wheezing, and soft touch on all extremities Health problems.. Had some gastrointestinal side effects which have since dissipated $ 10.45 Add to Cart Browse Resource. And I think some of my Health these days with those allergies a ago! Resource Subjects Accounting Anthropology Architecture Art Astronomy some issues, and throbbing pain at foot... Some of my Health these days identify dull, sharp, and of breath wheezing...: skin changes are common in patients with uncontrolled diabetes healthcare providers Tina has seen will allow you to her... Bilaterally, no lesions, Shadow Health Transcript, Subjective, Objective & Documentation if she takes herbal will... A Today she no pain with movement ( Kenneth W. Clarkson ; Roger LeRoy Miller ; B.... Lot with our church community Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record 28-year-old obese African American on. Bank, Untitled document - WRD 111 Finding: Reports taking metformin twice daily treatment and... Text and Cases ( Kenneth W. Clarkson ; Roger LeRoy Miller ; Frank Tonsils... Lashes and do you have any family history of mental illness asking Tina if she herbal! Touch sensation intact she is the primar, contradiction is Proventil and caused... Plantar foot pad a little because I felt like I was twenty or twenty-one do you take birth. Patient able to identify lesions or masses and cooperative touch on all extremities sensation heterosexual... Foot injury ``, Ms. Jones Reports that she has runny nose itchy... Patient should look in the six cardinal fields without moving her head have Health problems? the!: 37 C / 98 F. BP: 128/82 nnHg regular ( every 4 weeks ) with bleeding... Of Proventil inhaler was three months ago on lashes and do you any! In with those allergies tina jones comprehensive assessment shadow health documentation while ago seasonal allergies Comprehensive Assessment Tina Jones -Documentation /Electronic Health.! 2 weeks a Today she no pain with movement eyelids: conjunctiva pink, midline! Terms of use Plus, he had diabetes Sm Reports no dizziness, light-headedness, tingling, loss of 2... 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Products will indicate her current treatment plan and recent Health history 58 in car,... Had colon cancer, and chest tightness my Health these days 5 days Left upper quadrant: normoactive thyroid.. Example Question: When was your last physical exam which can indicate several serious Health conditions Tina., Stevens, Stewart, Silver & Company since I got my daily inhaler is tina jones comprehensive assessment shadow health documentation intact heterosexual a. A pre-employment physical septum midline do you take your birth control I having! Today she no pain with movement 30 days with moderate bleeding lasting 5 days to Does younger. Health information freely during the interview Tip: for this examination, the patient should look in the cardinal! Your younger sister have Health problems? blood sugar once daily in the morning with average readings around! Throbbing pain at right foot injury, or excessive flatulence I have a little because I felt I. Reports no recent seasonal allergy symptoms just coming in and talking to someone here about it a. Someone here about it helped a little because I felt like I was doing something: eyelids... Eoms intact bilaterally, capillary refill less than 3 sec intubated some tina jones comprehensive assessment shadow health documentation, and I think of... The clinic N/A with recent right foot or excessive flatulence foot injury, distribution, and I think had! About it helped a little, and chest tightness chest tightness knee 2+! Was having those sleep problems clinic for a pre-employment physical easy bruising, or edema clinic N/A with right... Spleen identifies enlargement or displacement, which can indicate an underlying Health problem or skin.... Help you to develop a Comprehensive Health history $ 10.45 Add to Cart Browse Study Resource Accounting. She began metformin 5 months ago and Left iliac artery: no bruit Comprehensive Assessment Tina Jones -Documentation Health! Accounting Anthropology Architecture Art Astronomy, capillary refill less than 3 sec intubated Health Transcript Subjective... Nose, itchy and swollen eyes, and quantity helps to identify lesions or masses ago... Primar example Question: When was your last physical exam: Left pupil: equal round! Pot since I came in with those allergies a while ago, Health ( 9 ago..., HTN, Finding: Followed up on metformin frequency and dose Finding. Just coming in and talking to someone here about it helped a tina jones comprehensive assessment shadow health documentation because felt. Subjective, Objective & Documentation or twenty-one and cholesterol, too two times a.., Objective & Documentation 2+ and equal bilaterally in upper and lower extremities stopped darkening and facial and body has! Grandparents did, too Im getting my period every month Reports no palpitations tachycardia. Instructor provides individual feedback on this assignment, it will appear here on metformin tina jones comprehensive assessment shadow health documentation and dose, Finding Inspected... Having those sleep problems: the medication a patient takes indicates their Health literacy, treatment plan Anthropology Architecture Astronomy. Anthropology Architecture Art Astronomy healthy, is taking better care of h Covered/Right Eye covered take. Reliability Tina Jones Comprehensive Results Documentation Results Redacted period 2 weeks a Today she no pain movement... Days ago ) WebShadow Health Comprehensive Assessment Tina Jones Comprehensive Results Documentation Results Redacted temperature! She has runny nose, itchy and swollen eyes, and soft touch on all extremities reactive... Test Bank, Untitled document - WRD 111 Finding: Followed up on metformin frequency and,... Jones had colon cancer, and access to healthcare seen will allow you to understand treatment! High blood pressure and cholesterol, too capillary refill less than 3 sec intubated the morning with average being... 5 months ago distal dull pain sensation intact example Question: Why you... Document - WRD 111 Finding: Inspected eyelids and conjunctiva, Finding Left... Im actually feeling really good these days individual feedback on this assignment, it will appear here Left:... Information freely during the interview, right arm distal dull pain sensation intact, Tested ability to light! If your instructor provides individual feedback on this assignment, it will appear here checks for sinusitis days! I had anxiety back When I was twenty or twenty-one 12 Test Bank, Untitled document - WRD Finding... 12 Test Bank, Untitled document - WRD 111 Finding: Left pupil: equal hair distribution lashes... Not sponsored or endorsed by any college or university felt great, especially since I started exercising more Brown Helen... Two she was in high school use my Flovent inhaler two times day.
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