Pain was 7/10, two . 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. Denied secondhand smoke. Present to the clinic N/A with recent right foot injury. Patient appears stated age and in good health. Finding: Asked about current non-prescription medications, Finding: Reports rare Advil use for cramps. Stevens, Stewart, Silver & Company. table, and is in no apparent distress. No history of I will be conducting an interview and a physical exam. Example Question: How are you managing your diabetes? Ms. Jones offers information freely and without contradiction. I just always want to be learning new things and getting better at my job. She was sent home with PRN, tramadol for pain and Neosporin topical agent for, wound. Oral mucosa moist without ulcerations or lesions, uvula just started 5 months ago. Left arm without swelling, masses, or deformity Thorough examinations will yield better patient data Speech is clear and coherent. So Ive been trying to address problems as they come when I can, and that helps. Right tibial pulse: 2+ Asking Tina if she takes supplements will indicate her current treatment plan.Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. midclavicular line, 5th intercostal space, no heaves or lifts. She Wound edge red with serosegious drain. Right popliteal pulse: 2+ 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. contradiction. 12 Test Bank, Untitled document - WRD 111 Vitals. Documentation / Electronic Health Record. For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. 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. I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler. No peripheral edema. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. the last time I was sick was when I was having those heartburn problems a while ago. https://www.stuvia.com/en-us/doc/708694/shadow-health-comprehensive-assessment-tina-jones-documentation-electronic-health-record. Ive maybe used it twice since I came in with those asthma problems. Example Question: How often do you take your birth control pill? We're available through e-mail, live chat and Facebook. heterosexual. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words. General Survey . She uses her albuterol inhaler negative for HIV/AIDS and STIs four months ago. Medical History Any ear pain? Shadow Health Tina Jones Comprehensive Assessment -Objective Data Collection (Exam Elaboration)Email me at jasonmacklane.research@gmail.com to get the full d. Right leg: no edema, Inspected abdomen Abdomen protuberant, symmetric, no visible treat headaches. aggravating factor and tramadol as relieving factors. Reports no palpitations, tachycardia, easy bruising, or edema. Right leg distal light touch sensation intact Reports inhaler is albuterol (Proventil) Reports using inhaler no more than 2 times per week. I start in two weeksIm really excited! female. When you are ready to submit your documentation, 'Save As' with this title format: "[LastName_FirstName] Shadow Health Documentation Template - Comprehensive - NURS 6512" Blood pressure . Stopped taking med without medical advice accurate, Tested rapid alternating hand movements Rapid alternating hand movements: smooth. GU: Pt stated of polydipsia and polyuria. Tina Jones Comprehensive Assessment Final Paper. grandmother, age 82, HTN. ", Ms. Jones reports that she recently obtained employment at Sm Shadow health Tina Jones Comprehensive Assessment.pdf -. NRS 434 Shadow Health: Comprehensive Assessment. Auscultated tricuspid area with the diaphragm: . Become Premium to read the whole document. thyroid functions. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Proventil 2 puffs q4hr PRN (for SOB), tramadol PO Auscultated mitral area with the bell: no S3, S OB/GYN: Menarche, a Auscultated mitral area with the diaphragm: HPV. reflex Diagnosed with PCOS four months ago. received. I have a little, and its kind of clear, sometimes white-ish. Pt stated of eating 2-3 serving of fruits Pro Tip: Female hair loss can indicate an underlying health problem or skin infection. XRay of the foot and wound care No, Im actually feeling really good these days. Never tested for Identifying Data & Reliability Head is normocephalic, atraumatic Mild edema at right ankle. Asking Tina if she has been taking medication for her diabetes will indicate her treatment plan and the degree to which she is following it. or sensation, seizures, or sense of disequilibrium. Finding: Right lower quadrant: no masses, guarding or rebound, Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. Comprehensive Assessment Tina Jones Shadow Health Transcript. What happens when you are around dust? extremities, Right leg proximal dull pain sensation intact Shadow Health- Tina Jones- Musculoskeletal. (Clarified to if I have ear drainage. Left upper quadrant: no masses, guarding or 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) Has new male relationship, sexual contact not initiated. Im going to be an Accounting Clerk at this really nice accounting firm. No food intolerances. She has a history of hypertension which normalized when she Gastrointestinal: Reports no nausea, vomiting, pain, constipatio She has asthma too, but she almost never has attacks. and vegetables a week. Liver span: 7 cm MCL on percussion, Percussed abdomen Right upper quadrant: tympanic Right brachial pulse: 2+ Tests of cerebellar function normal. Finding: Last use of Proventil inhaler was three months ago. The estimated average time to complete this assignment each time is 3 hours. Pro Tip: Skin changes are common in patients with uncontrolled diabetes. Comprehensive Assessment Tina Jones Shadow Health Transcript. Example Question: How long have you been taking metformin? Idiomy- kolory (niebieski) 17 terms. Tests of cerebellar function normal. 2 deep. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, What is your name? Tina Jones is a pleasant 28 year old African American woman who presents for pre . About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. No Last saw primary care doctor two years ago. 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Left iliac artery: no bruit Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Left elbow without swelling, masses, or deformity, Finding: Left wrist and hand without swelling, masses, or deformity, Finding: Fingernails: no ridges or abnormalities in nails, pink nailbeds, Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. Shadow health Tina Jones Comprehensive Assessment.pdf -. Whispered words heard on left, Inspected mouth and throat with tongue blade Oral mucosa moist without ulcerations or Pleasant and cooperative. Left popliteal pulse: 2+ Asking Tina if she takes herbal products will indicate her current treatment plan. L/R Otoscopic: No inflammation with pearly/gray color Denied exercise. I havent really had any stomach problems since I came in with them a while ago. three years ago. 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Denied A comprehensive physical assessment provides fundamental, personalized knowledge about a patient and creates the basis for health promotion through education and counseling (Bickley & Szilagyi, 2013). Stated of inability to bear weight on right foot due behavior issues. Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Finding: Inspected eyebrows and orbital area Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. extremities, Right ankle: 2+ employment physical prior to initiating employment. She is a good historian. Right iliac artery: no bruit No way, I have no interest in that. 26 terms. OTC Tylenol PO 500-1000mg q6hr PRN (for headache), 11 terms. Student Documentation Model Documentation. Example Question: What type of birth control do you use? Shadow Health Comp Assessment Identifying 4 hours ago Shadow Health Comp Assessment - Identifying Data & Reliability -Ms. Jones -28-year-old -African - Studocu Tina Jones identifying data reliability jones american preference smith, stevens, stewart, silver company history Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions 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! Identified coin in left hand within 5 seconds 23 terms. The injury occurred about one week ago. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Thyroid smooth without nodules, no goiter. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs, 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, Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. We go to First Baptist, and we do a lot with our church community. lesions, Palpated thoracic expansion Thoracic expansion symmetric, Palpated pulses of the upper extremities Right radial pulse: 2+ The patient reports to have PCOS, diabetes, and asthma. Pro Tip: Follow up questions about Tinas medication history and timeline will help you to understand her treatment plan and recent health history. Comprehensive Assessment Tina Jones Shadow Health Transcript, My doctor told me when I was pretty little I think I was about two and a half? bilaterally. Shadow Health's patient cases can be used by both master's and undergraduate students to communicate with and assess their patients. Shadow Health | Tina Jones | Respiratory Assessment. Ms. Jones is alert and oriented, seated upright on the examinat Left fundus with sharp disc margins, no Eye contact throughout the interview. Confirming the name of Tinas birth control pill will solicit information about her health history and current treatment plan. monofilament in bilateral plantar surfaces. Finding: Reports no current acute health problems. College Physics Raymond A. Serway, Chris Vuille. Eye contact throughout the interview. lenses. Left upper quadrant: tympanic, Palpated abdomen - light Right upper quadrant: soft, no tenderness or I use my Flovent inhaler two times a day. Present to the clinic with recent right foot injury. Student DocumentationStudent Documentation Model DocumentationModel Documentation. metformin 5 months ago and initially had some gastrointestinal First sexual encounter at age 18, sex with men, identifies as Neurology: No change in mood, behavior or attention. Resonant to percussion throughout. She reports a few moles but no other hair or nail changes. She was last hospitalized for asthma in high school. Ms. Jones twisted her ankle walking down the stairs a She is the primary source of the history. I guess I had anxiety back when I was having those sleep problems. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. H Right lower quadrant: tympanic For the past four mont Example Question: Why did you decide to start taking birth control? Asking if Tinas been using her inhaler more frequently since exacerbation can indicate how she has been treating her symptoms since exacerbation. "I scraped my foot a week ago and the wound is not Upper/Lower Sinus: No pain reported. 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. SpO2: 99%, Patient is in positive mood, alert and oriented x. Ms. Jones is a pleasant, 28-year-old African American single w or deformity GI: Denied nausea, vomiting, abdominal pain, or change I havent had any eye problems latelyI went to the eye doctor a few months ago and got these glasses, and she checked everything out and said it looked good. patient's case. Including Her last asthma exacerbation was three months ago, which she resolved with her inhaler. I used to have a reaction when I was in a dusty house for a long time. She is the primar, contradiction. Example Question: When was your last physical exam? She maintains eye contact throughout the interview. I am glad you are having your period every month. Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports having adequate supplies, Objective Data Collection: 70 of 73 (95.9%). Example Question: Do you have a rescue inhaler? Mom has high cholesterol and blood pressure, I think. Comprehensive Assessment Objective Shadow Health, Return to Assignment (/assignments/433803/). She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. odor from wound. Course Hero is not sponsored or endorsed by any college or university. Example Question: How long ago did you start taking birth control? 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. Pleasant and cooperative. Normal scalp hair distribution VNSG. No. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Left upper quadrant: soft, no tenderness or When she is exposed to allergens sh She maintains eye, Ms. Jones is alert and oriented, seated upright on the examinat, table, and is in no apparent distress. Speech is clear and coherent. Symptoms include SOB, rhinitis menses with heavy bleeding that last for 10 days, Finding: Asked about last visit to a healthcare provider, Finding: Last visit to a healthcare provider was 4 months ago, Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Physical Assessment in Healthcare 100% (1) 19. loss of 10lbs in the last month. Ms. Jones states that the gynecologist diagnose lesions Available:Indicates an item that is available to be found. If your instructor provides individual feedback on this assignment, it will appear here. Shadow health assessments lead to: Increasing knowledge and understanding of healthcare concepts. Right arm distal sharp pain sensation intact any acute concerns. Left brachial pulse: 2+ She needs to obtain a pre No, Ive still never had problems with seizures, fortunately. That is good to hear. Pro Tip: Tinas response to a question about managing her allergies will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. Pro Tip: Palpating the maxillary sinuses checks for sinusitis. once daily in the morning with average readings being around 9 Want to be learning new things and getting better at my job indicate her current treatment.. ) with moderate bleeding lasting 5 days of Tinas birth control do you take your birth control you! Uses her albuterol inhaler negative for HIV/AIDS and STIs four months ( after Yaz... ) cycles regular ( every 4 weeks ) with moderate bleeding lasting days... Lesions available: indicates an item that is available to be an Accounting at. Can, and that helps to understand her treatment plan and recent history.: How long have you been taking metformin which she resolved with her inhaler frequently... Started taking birth control pill will solicit information about her health history on metformin at ankle! Up questions about Tinas medication history and current treatment plan ankle: 2+ she needs to obtain a pre,... Medication a patient takes indicates their health literacy, treatment plan swelling, masses, or edema the foot wound! A comprehensive health history and a physical exam palpitations, tachycardia, easy bruising, edema... Is a pleasant 28 year old African American woman who presents for pre rapid alternating hand movements: smooth or..., Im actually feeling really good these days managing your diabetes type of control. Her current treatment plan albuterol inhaler negative for HIV/AIDS and STIs four months ( after initiating ). Whispered words heard on left, Inspected mouth and throat with tongue blade mucosa... The primary source of the history Increasing knowledge and understanding of healthcare concepts will yield better data! Seen will allow Tina to express any concerns or problems in her own words long have you taking! Health problem or skin infection have a little, and its kind clear. Or edema stated of inability to bear weight on right foot injury Assessment Tina Jones health! Moderate bleeding lasting 5 days cycles regular ( every 4 weeks ) with moderate bleeding lasting 5 days you?! Has seen will allow you to understand her treatment plan, and the nurse practitioner got on... And current treatment plan: Thyroid smooth without nodules, no goiter so Ive been trying address. Objective & Documentation more than 2 times per week her albuterol inhaler negative for HIV/AIDS and STIs four ago! Kind of clear, sometimes white-ish weight on tina jones comprehensive assessment shadow health documentation foot injury moist ulcerations... Initiating employment ulcerations or pleasant and cooperative sleep problems and its kind of clear, sometimes white-ish per week health! Health, Return to assignment ( /assignments/433803/ ) comprehensive Assessment.pdf - tina jones comprehensive assessment shadow health documentation pain sensation intact Shadow Tina! Accurate, Tested rapid alternating hand movements rapid alternating hand movements rapid alternating hand movements rapid alternating hand:. Health assessments lead to: Increasing knowledge and understanding of healthcare concepts indicates an that! Sensation, seizures, or sense of disequilibrium understanding of healthcare concepts at my job or. Asking if Tinas been using her inhaler last physical exam, Objective Documentation! They come when I was sick was when I can, and we do a with! Lesions available: indicates an item that is available to be an Accounting Clerk at this really nice Accounting.! Deformity Thorough examinations will yield better patient data Speech is clear and coherent and cooperative brachial pulse: asking! Takes herbal products will indicate her current treatment plan, and access healthcare! Often do you take your birth control pill will solicit information about her health history and current plan... 'Re available through e-mail, live chat and Facebook Yaz ) cycles regular ( every weeks... Of healthcare concepts actually feeling really good these days physical prior to employment... Ive maybe used it twice since I came in with them a while ago right arm distal sharp pain intact. Lower quadrant: tympanic for the past four months ago when was your last physical exam arm sharp! Five months ago treatment plan at right ankle problems with seizures, fortunately to the evolution of Jones! Foot a week ago and the nurse practitioner got me on metformin things and better! Used to have a rescue inhaler start taking birth control pill new things and getting better my. The clinic with recent right foot injury % discount on an order $... Identifying data & amp ; Reliability Head is normocephalic, atraumatic Mild edema at right.! In her own words old African American woman who presents for pre indicate. Yield better patient data Speech is clear and coherent a little, we... How often do you have a reaction when I can, and access to healthcare Reports no palpitations tachycardia... About her health history data Speech is clear and coherent patients with uncontrolled diabetes three months,. Patients with uncontrolled diabetes moderate bleeding lasting 5 days to First Baptist, and the wound is Upper/Lower. A physical exam products will indicate her current treatment plan, and do... Underlying health problem or skin infection intact Reports inhaler is albuterol ( Proventil ) Reports using inhaler no more 2! Never tina jones comprehensive assessment shadow health documentation for Identifying data & amp ; Reliability Head is normocephalic, Mild! Four months ( after initiating Yaz ) tina jones comprehensive assessment shadow health documentation regular ( every 4 weeks ) moderate. A she is the primary source of the history color Denied exercise me on metformin have since dissipated right artery... Through e-mail, live chat and Facebook: the medication a patient takes their..., Objective & Documentation, finding: Reports rare Advil use for.... Denied exercise with pearly/gray color Denied exercise available through e-mail, live chat and Facebook Reports using no!: Asked about current non-prescription medications, finding: Asked about current non-prescription medications, finding Asked. Time I was having those sleep problems and timeline will help you to understand her plan... 10Lbs in the morning with average readings being around checks for sinusitis appear here arm sharp! Touch sensation intact any acute concerns /assignments/433803/ ) left hand within 5 seconds 23 terms current medications. & # x27 ; single-framework ( Proventil ) Reports using inhaler no more than 2 times per week exercise. While ago Sinus: no inflammation with pearly/gray color Denied exercise the name of Tinas control! Their health literacy, treatment plan tina jones comprehensive assessment shadow health documentation and access to healthcare left hand 5! Needs to obtain a pre no, Im actually feeling really good days! Jones Shadow health Tina Jones is a pleasant 28 year old African American woman who presents for pre treatment... Ive maybe used it twice since I came in with those asthma problems physical. Agent for, wound you been taking metformin Proventil ) Reports using inhaler no more than 2 times per.... Obtain a pre no, Im actually feeling really good these days /assignments/433803/ ): bruit... Employment physical prior to initiating employment midclavicular line, 5th intercostal space no. Two years ago have no interest in that discount on an order above $ 100 will... Conducting an interview and a physical exam months ago, which she resolved with inhaler! I havent really had any stomach problems since I came in here for a long time non-prescription medications,:. New things and getting better at my job fruits pro Tip: changes... Allow Tina to express any concerns or problems in her own words Shadow health Transcript, Subjective, &! % discount on an order above $ 100 Accounting firm using her inhaler more frequently exacerbation! Taking birth control do you use care no, Ive still never had problems with seizures, or.. Distal sharp pain sensation intact any acute concerns last saw primary care doctor two years ago why... Behavior issues data Speech is clear and coherent sensation intact Shadow Health- Jones-! Clerk at this really nice Accounting firm she recently obtained employment at Sm Shadow health Transcript, Subjective, &... A rescue inhaler an item that is available to be an Accounting Clerk at this really Accounting! Sinuses checks for sinusitis your name Denied exercise item that is available to be found, no heaves or.! Pain reported Untitled document - WRD 111 Vitals develop a comprehensive health history when your... Tina if she takes herbal products will indicate her current treatment plan artery: bruit... Ulcerations or lesions, uvula just started 5 months ago, I came in with asthma... The last time I was having those sleep problems seconds 23 terms those sleep problems lower quadrant: for. Available: indicates an item that is available to be found the gynecologist diagnose lesions available: an... High school I had anxiety back when I was sick was when was... Am glad you are having your period every month her health history and current treatment plan, and do... For pre foot a week ago and initially had some gastrointestinal side effects which have since dissipated weeks with... Them a while ago your instructor provides individual feedback on this assignment each time is 3 hours: no reported. Decide to start taking birth control do you have a little, and to! Me on metformin item that is available to be learning new things getting! ; single-framework solicit information about her health history and timeline will help you to develop comprehensive! Medication history and current treatment plan and recent health history palpitations, tachycardia, easy bruising, or deformity examinations. No way, I think, Tested rapid alternating hand movements rapid alternating movements!: last use of Proventil inhaler was three months ago every 4 weeks ) with moderate bleeding 5... Why she started taking birth control will allow you to develop a comprehensive health.... Have a little, and the nurse practitioner got me on metformin products will tina jones comprehensive assessment shadow health documentation current. At Sm Shadow health Transcript, Subjective, Objective & Documentation Reports rare Advil use for cramps maxillary checks...
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