Start your exams prepared!: 2026/2027// Q&A 2026///2027 #studyguide. // Start your exams prepared!
Objective Data Collection
Documentation Vitals
Plan My Exam Student Documentation Model Documentation
« Height: 170 cm
« Weight: 84 kg
Vitals * BMI: 29.0
* Blood Glucose: 100
BP: 142/82; HR: 68; RR: 16; 02: 98%: Temperature: *RR: 15
379C *HR: 78
+BP:128/82
« Pulse Ox: 99%
« Temperature: 99.0 F
Health History
Student Documentation Model Documentation
Identifying Data & Reliability Ms. Jones is a pleasant, 28-year-old African
Patient is in no apparent distress. Alert and oriented American single woman who presents for pre-
‘employment physical. She is the primary source of
x4, Patient is seated upright on the examination the history. Ms. Jones offers information freely and
table, she is well nourished, and dressed without contradiction. Speech is clear and coherent
appropriately for the weather with good hygiene. She maintains eye contact throughout the interview.
hups://www.coursehero.com/file/38245035/Comprehensive- Assessment-Completed-Shadow-Healthpdf/
https://app.shadowhealth.com/assignment_attempts/4562098 "
212412019 Comprehensive Assessment | Completed | Shadow Health
‘ Studunt Docurneitation Moc.:. L‘m.d..'.t..’lla;}vn
e
1 1 first-attempt success and A+ Grade
, Start your exams prepared!: 2026/2027// Q&A 2026///2027 #studyguide. // Start your exams prepared!
Student Documentation Model Documentation
General Survey
Tina Jones is a pleasant 28 year old African Ms. Jones is alert and oriented, seated upright on
American woman who presents for pre-employment the examination table, and is in no apparent distress.
physical. She offers information freely and without She is well-nourished, well-developed, and dressed
contradiction. Beach is clear and coherent and appropriately with good hygiene.
maintains eye contact throughout the interview.
Patient denies any current pain.
Reason for Visit
“I came in because I'm required to have a recent
*I came in because I'm required to have a recent
physical exam for the health insurance at my new
physical examination for the health insurance at my job."
new job"
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 concens. Her last healthcare visit
was 4 months ago, when she received her annual
gynecological exam at Shadow Health General
History of Present lliness Clinic. Ms. Jones states that the gynecologist
diagnosed her with polycystic ovarian syndrome and
Denies any pain or present illness 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 the
new job.
« Metformin, 850 mg PO BID (last use: this morning)
« Drospirenone and ethinyl estradiol PO QD (last
Medications use: this morning)
« Albuterol 90 meg/spray MDI 1-3 puffs Q4H pr (last
Metformin QD, Yaz QD, Inhaler PRN, "never more
than twice a week, sometimes not at all"
use: yesterday)
+ Acetaminophen 500-1000 mg PO prn (headaches)
« Ibuprofen 600 mg PO TID pm (menstrual cramps:
last taken 6 weeks ago)
« Penicillin: rash
Allergies « Denies food and latex allergies
« Allergic to cats and dust. When she is exposed to
Penicillin; rash/ hives.
allergens she states that she has runny nose, itchy
and swollen eyes, and increased asthma symptoms.
2 2 first-attempt success and A+ Grade
Objective Data Collection
Documentation Vitals
Plan My Exam Student Documentation Model Documentation
« Height: 170 cm
« Weight: 84 kg
Vitals * BMI: 29.0
* Blood Glucose: 100
BP: 142/82; HR: 68; RR: 16; 02: 98%: Temperature: *RR: 15
379C *HR: 78
+BP:128/82
« Pulse Ox: 99%
« Temperature: 99.0 F
Health History
Student Documentation Model Documentation
Identifying Data & Reliability Ms. Jones is a pleasant, 28-year-old African
Patient is in no apparent distress. Alert and oriented American single woman who presents for pre-
‘employment physical. She is the primary source of
x4, Patient is seated upright on the examination the history. Ms. Jones offers information freely and
table, she is well nourished, and dressed without contradiction. Speech is clear and coherent
appropriately for the weather with good hygiene. She maintains eye contact throughout the interview.
hups://www.coursehero.com/file/38245035/Comprehensive- Assessment-Completed-Shadow-Healthpdf/
https://app.shadowhealth.com/assignment_attempts/4562098 "
212412019 Comprehensive Assessment | Completed | Shadow Health
‘ Studunt Docurneitation Moc.:. L‘m.d..'.t..’lla;}vn
e
1 1 first-attempt success and A+ Grade
, Start your exams prepared!: 2026/2027// Q&A 2026///2027 #studyguide. // Start your exams prepared!
Student Documentation Model Documentation
General Survey
Tina Jones is a pleasant 28 year old African Ms. Jones is alert and oriented, seated upright on
American woman who presents for pre-employment the examination table, and is in no apparent distress.
physical. She offers information freely and without She is well-nourished, well-developed, and dressed
contradiction. Beach is clear and coherent and appropriately with good hygiene.
maintains eye contact throughout the interview.
Patient denies any current pain.
Reason for Visit
“I came in because I'm required to have a recent
*I came in because I'm required to have a recent
physical exam for the health insurance at my new
physical examination for the health insurance at my job."
new job"
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 concens. Her last healthcare visit
was 4 months ago, when she received her annual
gynecological exam at Shadow Health General
History of Present lliness Clinic. Ms. Jones states that the gynecologist
diagnosed her with polycystic ovarian syndrome and
Denies any pain or present illness 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 the
new job.
« Metformin, 850 mg PO BID (last use: this morning)
« Drospirenone and ethinyl estradiol PO QD (last
Medications use: this morning)
« Albuterol 90 meg/spray MDI 1-3 puffs Q4H pr (last
Metformin QD, Yaz QD, Inhaler PRN, "never more
than twice a week, sometimes not at all"
use: yesterday)
+ Acetaminophen 500-1000 mg PO prn (headaches)
« Ibuprofen 600 mg PO TID pm (menstrual cramps:
last taken 6 weeks ago)
« Penicillin: rash
Allergies « Denies food and latex allergies
« Allergic to cats and dust. When she is exposed to
Penicillin; rash/ hives.
allergens she states that she has runny nose, itchy
and swollen eyes, and increased asthma symptoms.
2 2 first-attempt success and A+ Grade
