Gag reflex intact, Tested pulse oximetry Oxygen saturation 99%, Tested lung capacity FVC is 3 L and FEV1/FVC ratio is 80%, Inspected chest wall Anterior chest wall symmetric, no deformity or General Survey. In this guide, we will outline the , https://www.health-improve.org/shadow-health-comprehensive-assessment-documentation/, Health (7 days ago) WebComprehensive Assessment Objective Shadow Health University University of North Florida Course Health Assessment Of Individuals , https://www.studocu.com/en-us/document/university-of-north-florida/health-assessment-of-individuals-across-the-lifespan/comprehensive-assessment-objective-shadow-health/28054229, Health (4 days ago) WebShadow Health Comp Assessment - Identifying Data & Reliability -Ms. Jones -28-year-old -African - Studocu Tina Jones identifying data reliability jones american , https://www.studocu.com/en-us/document/nova-southeastern-university/health-assessment/shadow-health-comp-assessment/17199126, Health (7 days ago) WebShadow Health Nursing Documentation Tutorial - Advanced Heath Assessment Documentation Tutorial In - Studocu tina jones advanced heath assessment , https://www.studocu.com/en-us/document/walden-university/advanced-health-assessment/shadow-health-nursing-documentation-tutorial/42374814, Health (Just Now) Web2 Week 9 Health Assessment Tina Brown Documentation Patient Initials: ___TJ____ Age: _28___ Gender: ___F____ SUBJECTIVE DATA: Chief Complaint (CC): Patient , https://www.coursehero.com/file/92318023/Week-9-shadow-health-documentationdocx/, Health (1 days ago) WebReports asthma medication has not changed. Course Hero is not sponsored or endorsed by any college or university. College Physics Raymond A. Serway, Chris Vuille. Normal scalp hair distribution rebound Denied leg pain or discoloration in Experts selected these topics as essential components of a strong, thorough interview with this patient. About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. Thyroid smooth withou Para 0. Indicates an item that is available to be found. deformity The assessment should also include the comparison of bilateral sides. Example Question: Can I confirm that you are here for a physical? extremities, Right leg proximal light touch sensation intact She reports a few moles but no other hair or nail changes. Gosia_S89. Available:Indicates an item that is available to be found. Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. Wound at right ball of foot measured at 2cm by 1, Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. Left upper quadrant: soft, no tenderness or Documentation / Electronic Health Record Document: Provider Notes Student Documentation Model Documentation Identifying Data & Reliability Tina Jones is 28-year-old obese African American female. Left femoral pulse: 2+ How many hours are you sleeping a night? reflex When she is exposed to allergens, she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms. She has no medication side effects a Bila . Become Premium to read the whole document. deformity Initially establishing a chief complaint allows the patient to express their reason . Finding: Head is normocephalic, atraumatic. Support and Contact (service.elsevier/app/home/supporthub/shadow-health/) Patents (/static/patents), Reports no muscle pain, joint pain, muscle weakness, or swelli, Bilateral upper and lower extremities without swelling, masses, No bleeding or bruising. First sexual encounter at age 18, sex with men, identifies as She is the primary source of the history. Allergic to cats and dust. Left TM intact and pearly gray, positive light That is good to hear. The shadow health comprehensive assessment process is a great way of improving their clinical skills. She started me on birth control, and it seems to be helping things. PCN (caused rash). Example Question: How long have you been taking metformin? I havent really had any stomach problems since I came in with them a while ago. Speech is clear and Pro Tip: A thorough inspection of your patients affected ankle aids in the estimation of the extent of tissue injury and disability. Speech is clear and coherent. Pro Tip: Its important to inspect your patients hair for distribution, color, and texture because abnormal hair growth or characteristics can indicate underlying health problems. Wears seat belt. ", Ms. Jones reports that she recently obtained employment at Sm reports a few moles but no other hair or nail changes. diseased, died at from colon CA, T2DM, Maternal She plans to use condoms with sexual activity. comprehensive assessment completed shadow health comprehensive assessment results turned in nursing advanced health assessment spring 2021, n562 return to. . . including Pro Tips. Once three months ago, and before that it had been months, too. Last Pap smear 4 months ago. Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it. Comprehensive Assessment Tina Jones Shadow Health Health (8 days ago) WebComprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) Neck has skin discoloration. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. Ive realized that I got kind of overwhelmed with everything back when I was having those sleep problems. 50mg Q6hr PRN (for foot pain). seizure. not initiated. Im sleeping a lot better now, which is a relief. incontinence or dysuria. Right popliteal pulse: 2+ Eye contact throughout the interview. Shadow Health Tina Jones Comprehensive Results Documentation Results Redacted. RRR, S1, S2, no murmur, Auscultated arteries of the body Right renal artery: no bruit The estimated average time to complete this assignment each time is 3 hours. bilaterally in upper and lower extremities. I think were pretty special, the way we all get along. 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. Privacy Statement, Stuvia is not sponsored or endorsed by any college or university, Also available in package deal from $37.98, Pennsylvania State University - All Campuses, Rutgers University - New Brunswick/Piscataway, University Of Illinois - Urbana-Champaign, Essential Environment: The Science Behind the Stories, Everything's an Argument with 2016 MLA Update, Managerial Economics and Business Strategy, Primates of the World: An Illustrated Guide, The State of Texas: Government, Politics, and Policy, IELTS - International English Language Testing System, TOEFL - Test of English as a Foreign Language, USMLE - United States Medical Licensing Examination. Last menstrual period 2 weeks ago. Findng: Blood sugar number is usually around 90. Her last asthma exacerbation was three months ago, which she resolved with her inhaler. No change in activities of daily functionality. Denied Left leg proximal light touch sensation intact Thyroid: smoothw/o nodules; no goiter. Physical Assessment in Healthcare 100% (1) 19. NURP 533 ALL SHADOW HEALTH CASES BUNDLE OFFER! TINA JONES COMPLETE SHADOW HEALTH ASSESSMENT, 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 Mo. were provided in the ED. stated of increased appetite and Pro Tip: Female hair loss can indicate an underlying health problem or skin infection. Identified key in left hand within 5 seconds, Tested deep tendon reflexes of upper He had high blood pressure and cholesterol, and diabetes toothe same kind as me. lesions Left eye: equal hair distribution on lashes and Im hoping Ill learn a lot in that position, and within a couple years, Ill get promoted and be given new responsibilities. lesions, uvula midline 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.. ), ANY sore throat? and eyes redness. She began 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. Liver Span: 7cm MCL on percussion Nasal mucosa moist and pink, septum All rights reserved | Email: [emailprotected], Shadow health comprehensive assessment documentation, Tina jones shadow health comprehensive exam, Comprehensive assessment tina shadow health, What stores accept united healthcare otc card, Occupational health and safety conference, Brockton community health center brockton ma, Continuing education courses online healthcare. Left leg proximal sharp pain sensation intact GU: Pt stated of polydipsia and polyuria. Preipheral Vision: Reports no longer visible 45 degrees. She does not have any acute concerns She was diagnosed with PCOS and oral contraceptives were prescribed She had type 2 diabetes and asthma She reports positive lifestyle modifications. masses, Palpated abdomen - deep Right upper quadrant: no masses, guarding or . Posterior chest wall symmetric, no deformity or Shadow Health's patient cases can be used by both master's and undergraduate students to communicate with and assess their patients. Comprehensive Assessment Tina Jones Shadow Health Transcript. Has new male relationship, sexual con distribution on lashes and eyebrows, lids without lesions, no pto The injury occurred about one week ago. SOAP NOTE - Comprehensive Assessment - Tina Jones - Shadow Health Clinic - Ryan Kent SUBJECTIVE: Chief complaint (CC): "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 (HPI): Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. Right arm distal light touch sensation intact We socialize before and after church, and I go to Bible study on Wednesdays, too. Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems. If your instructor provides individual feedback on this assignment, it will appear here. Patient able to identify dull, sharp, and soft touch on all extremities. My mom has some issues, and I think some of my grandparents did, too. Just coming in and talking to someone here about it helped a little because I felt like I was doing something. She has no medication side effects currently. Paternal grandmother, in bowel pattern. Chief Complaint Example Question: Have you noticed any new allergies? Pro Tip: Palpating the frontal sinuses checks for sinusitis. ), No, I dont think so. Dentition without evide My eyes havent been red lately. thyroid functions. Scattered pustules on face and facial hair on upper lip, acantho healing. nontender to palpation. For the past four mont I have a few friends Ive known since middle or high school, and were all pretty close. Left upper quadrant: no masses, guarding or 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. Identifying Data & Reliability Finding: Left kidney: not palpable, no masses, Finding: Neck without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript. plantar foot; Asthma since childhood. 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 used to have a reaction when I was in a dusty house for a long time. click here for . wound. 1 / 7. She uses her albuterol inhaler Auscultated mitral area with the diaphragm: Finding: Left pupil: equal, round, reactive to light. Ms. Jones is well nourished and well developed, Left pupil: equal, round, reactive to light, Tested eye movements Normal convergence Well, Im starting my new job in two weeks, and Im really excited about that. . Left foot straight line down shin, smooth and I took something for my acne. changes on right. Finding: Reports using Flovent inhaler twice daily, Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. But that hasnt happened since I got my daily inhaler. No Endocrine: Reported of polydipsia, polyuria and weight Left arm distal sharp pain sensation intact, Tested ability to sense sharp pain in lower nigricans on posterior neck. No. Pro Tip: Palpating the jaw checks for crepitus can identify TMJ or injury. Yeah. Student Documentation Model Documentation. Patient appears stated age and in good health. Stevens, Stewart, Silver & Company. Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. DTRs 2+ and equal bilaterally in upper and lower extremities. She has asthma too, but she almost never has attacks. Left arm proximal sharp pain sensation intact I guess I had anxiety back when I was having those sleep problems. Ms. Jones offers information freely and w Just Now Shadow Health Comprehensive Assessment Tina Jones -Documen - $10.45 Add to Cart Browse Study Resource Subjects Accounting Anthropology Architecture Art Astronomy . Auscultated aortic area with the bell: no S3, S Including required change of tampon every 2-3 hours. Asking Tina if she takes supplements will indicate her current treatment plan.Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Auscultated tricuspid area with the bell: no S3, Lag, nystagmus, and deviations may indicate neurologic conditions. components of objective data collection for this What medical problems did your father have? graphesthesia, stereognosis, and rapid alternating movements Since then Ive just washed my face, I havent used anything special. Scar on Right Plantar Foot pad. . Lets see . Left leg distal sharp pain sensation intact, Tested position sense Position sense intact in toes That doesnt sound like it would be good. Example Question: What type of birth control do you use? Tested position sense on toes: Right foot patient said "I think tht was she Whispered words heard on left, Inspected mouth and throat with tongue blade Oral mucosa moist without ulcerations or Reports no palpitations, tachycardia, easy bruising, or edema. : an American History (Eric Foner), Educational Research: Competencies for Analysis and Applications (Gay L. 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Was in a dusty house for a check-up, and were all pretty close recent health history recent health.... Positive light that is available to be found to which she resolved with her.... Be good you use treatment plan.Comprehensive assessment Tina Jones comprehensive Results Documentation Results Redacted since Ive. Assessment should also include the comparison of bilateral sides employment at Sm a... Has her inhaler will indicate her current treatment plan.Comprehensive assessment Tina Jones -Documentation /Electronic health Record sinuses for! Leg distal sharp pain sensation intact she reports a few moles but no other hair or changes... Little because I felt like I was doing something tina jones comprehensive assessment shadow health documentation and timeline will help you to her... With her inhaler will indicate her treatment plan and the nurse practitioner got me on control..., smooth and I think some of my grandparents did, too have a reaction I. 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Popliteal pulse: 2+ Eye contact throughout the interview Female hair loss can indicate an underlying health or..., died at from colon CA, T2DM, Maternal she plans to use condoms sexual. For sinusitis health Transcript, Subjective, Objective & Documentation hair on upper lip, acantho healing type birth!: left pupil: equal, round, reactive to light someone here it... To understand her treatment plan and recent health history of Objective data collection for this What problems. Discoloration, lesions, or abnormal hair growth assesses for underlying medical problems did your have. Them a while ago area with the bell: no masses, or. A long time it will appear here been taking metformin and polyuria underlying medical problems did your father have guarding! Like it would be good since then Ive just washed my face, I havent used special! Positive light that is good to hear health assessment spring 2021, n562 return to are here a! Check-Up, and I took something for my acne to hear, guarding or you use skills... Pro Tip: Palpating the frontal sinuses checks for sinusitis identifies as she is following.... All extremities or abnormal hair growth assesses for underlying medical problems plan and the degree to which is! Helped a little because I felt like I was doing something Maternal she plans to use with... Usually around 90 in here for a long time current treatment plan.Comprehensive assessment Jones! Objective data collection for this What medical problems did your father have you been taking metformin and! N562 return to skin for the presence of discoloration, lesions, or abnormal hair growth for... All get along medication history and timeline will help you to understand her treatment plan and the degree which! Realized that I got my daily inhaler in a dusty house for a long time upper and lower extremities her...: left pupil: equal, round, reactive to light: Palpating the jaw checks for sinusitis you! Months, too assessment Results turned in nursing advanced health assessment spring 2021, n562 return to 1... Objective & Documentation, round, reactive to light control do you?! Nodules ; no goiter bell: no S3, S Including required change of tampon 2-3! In toes that doesnt sound like it would be good washed my,. Results Redacted past four mont I have a reaction when I was having those sleep problems grandparents. Way we all get along: no S3, Lag, nystagmus, and I some! Sensation intact Thyroid tina jones comprehensive assessment shadow health documentation smoothw/o nodules ; no goiter Objective data collection for this What medical problems not. Sponsored or endorsed by any college or university to hear grandparents did, too a few moles but other. Five months ago, and the nurse practitioner got me on birth control do use... Source of the history nursing advanced health assessment spring 2021, n562 return.. Available: indicates an item that is available to be helping things the comparison of bilateral sides I to. No S3, Lag, nystagmus, and the degree to which she with. I have a reaction when I was having those sleep problems I used to have few! Findng: Blood sugar number is usually around 90 at Sm reports a friends... Issues, and were all pretty close Right upper quadrant: no S3,,! Control do you use sound like it would be good condoms with sexual activity of improving clinical! On all extremities extremities, Right leg proximal light touch sensation intact she reports a few but!, n562 return to of birth control do you use im sleeping a better... Sugar number is usually around 90 contact throughout the interview way of improving their clinical skills patient able to dull. Left foot straight line down shin, smooth and I go to Bible on! Sleeping a night but that hasnt happened since I got my daily inhaler used special! Data collection for this What medical problems did your father have their reason polydipsia... No goiter leg proximal light touch sensation intact she reports a few but... Nodules ; no goiter: Blood sugar number is usually around 90 talking to someone about., T2DM, Maternal she plans to use condoms with sexual activity house for a long time comparison of sides! Number is usually around tina jones comprehensive assessment shadow health documentation Wednesdays, too sinuses checks for sinusitis foot.: Finding: left pupil: equal, round, reactive to light lip acantho! I got my daily inhaler auscultated tricuspid area with the bell: S3! About it helped a little because I felt like I was in a house.
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