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Health History Results | Turned In
D028 - Advanced Health Assessment - November 2025, D028
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Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Document: Provider Notes
Objective Data Collection
Document: Provider Notes
Education & Empathy
Documentation Student Documentation Model Documentation
Health History Tips and Tricks
Identifying Data & Reliability
Ms. Jones is a 28-year-old African American single
Self-Reflection woman who presents to establish care and with a rec
Patient is alert and oriented, knows name and date of right foot injury. She is the primary source of the histo
birth. The patient is a reliable historian. The patient is and offers information freely, without contradiction.
able to give information about self and family history. Speech is clear and coherent. She maintains eye con
Patient is mentally and emotionally stable at this time. throughout the interview.
General Survey
Ms. Jones is alert and oriented, seated upright on the
Pt is aware that she needs to seek routine medical care. examination table, and is in no apparent distress. She
Patient has the access and resources to recive regular dressed appropriately with good hygiene.
medical attention, but not the education.
Chief Complaint
Patient is here with chief complaint of a right posterior “I got this scrape on my foot a while ago, and I though
foot wound. Pt wound is 2cm x 1.5cm and 2.5mm deep would heal up on its own, but now it's looking pretty
with serosanguenous draingage. Skin around wound is nasty. And the pain is killing me!”
red, and patient endorses chills and fever.
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Student Documentation Model Documentation
Ms. Jones reports that a week ago she tri
stairs outside, twisting her right ankle and
sought care in a local emergency departm
and was provided tramadol for pain. She h
History Of Present Illness a day and is applying antibiotic ointment a
ankle edema and pain have resolved but t
The patient endorses scraping her foot on a stair while walking. Pt has had increasingly painful. The pain is described
difficulty ambulating since accident requiring asisstance and having a weight bearing. She states her ankle “ach
negative impact on daily activities. Pt went to the ER for the wound and Pain is rated 7 out of 10 with medication,
given tramadol for pain. Patient endorses the wound has gotten worse, She reports that over the past two days th
despite washing regualrly and applying fresh bandages twice daily. swollen and increasingly red; yesterday sh
the wound. She denies any odor from the
she has been wearing slip-ons. She repor
Fahrenheit last night. She denies recent il
unintentional weight loss over the month a
change in diet or level of activity.
Acetaminophen 500-1000 mg PO prn (he
Medications
Ibuprofen 600 mg PO TID prn (menstrual
the patient only has an inhaler which she uses as needed when having
difficulty breathoing due to asthma flare up. Pt is not on medications for Tramadol 50 mg PO TID prn (foot pain)
diabetes.
Albuterol 90 mcg/spray MDI 2 puffs Q4H p
Allergies Medications: Penicillin (rash).
Patient is allergic to penicillin with unknown reaction. Environmental: cats and dust (runny nose
increased asthma symptoms).
Asthma diagnosed at age 2 1/2. She uses
around cats and dust. She uses her inhale
exposed to cats three days ago and had t
positive relief of symptoms. She was last
school”.
Type 2 diabetes, diagnosed at age 24. Sh
she stopped three years ago, stating that
Medical History was overwhelming, taking pills and check
monitor her blood sugar. Last blood gluco
Ptatient has asthma and untreated diabetes. emergency room.
No surgeries.
Menarche, age 11. Identifies as heterosex
menstrual period 3 weeks ago. For the pa
weeks) with heavy bleeding lasting 9-10 d
oral contraceptives in the past. When sex
use condoms. Never tested for HIV/AIDS.
symptoms. Last tested for STIs four years
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12/8/25, 2:20 PM | Shadow Health® │ Digital Clinical Experiences™ from Elsevier
Health History Results | Turned In
D028 - Advanced Health Assessment - November 2025, D028
Return to Assignment (/assignments/1272856/)
Your Results Reopen (/assignment_attempts/20532447/reopen
Lab Pass (/assignment_attempts/20532447/lab_pass.pd
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Document: Provider Notes
Objective Data Collection
Document: Provider Notes
Education & Empathy
Documentation Student Documentation Model Documentation
Health History Tips and Tricks
Identifying Data & Reliability
Ms. Jones is a 28-year-old African American single
Self-Reflection woman who presents to establish care and with a rec
Patient is alert and oriented, knows name and date of right foot injury. She is the primary source of the histo
birth. The patient is a reliable historian. The patient is and offers information freely, without contradiction.
able to give information about self and family history. Speech is clear and coherent. She maintains eye con
Patient is mentally and emotionally stable at this time. throughout the interview.
General Survey
Ms. Jones is alert and oriented, seated upright on the
Pt is aware that she needs to seek routine medical care. examination table, and is in no apparent distress. She
Patient has the access and resources to recive regular dressed appropriately with good hygiene.
medical attention, but not the education.
Chief Complaint
Patient is here with chief complaint of a right posterior “I got this scrape on my foot a while ago, and I though
foot wound. Pt wound is 2cm x 1.5cm and 2.5mm deep would heal up on its own, but now it's looking pretty
with serosanguenous draingage. Skin around wound is nasty. And the pain is killing me!”
red, and patient endorses chills and fever.
This study source was downloaded by 1827175 from cliffsnotes.com on 01-08-2026 20:14:57 GMT -06:00
https://wgu.shadowhealth.com/assignment_attempts/20532447 1/8
2026-01-09
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, ? Updated:
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2 of 8 Q&A || Complete Questions& Correct Answers || (100% Verified) ||| Latest Update||Guaranteed Pass A+| Fully
2 Start
Verified
your|| exams
? //full exam
prepared!
coverage!
12/8/25, 2:20 PM | Shadow Health® │ Digital Clinical Experiences™ from Elsevier
Student Documentation Model Documentation
Ms. Jones reports that a week ago she tri
stairs outside, twisting her right ankle and
sought care in a local emergency departm
and was provided tramadol for pain. She h
History Of Present Illness a day and is applying antibiotic ointment a
ankle edema and pain have resolved but t
The patient endorses scraping her foot on a stair while walking. Pt has had increasingly painful. The pain is described
difficulty ambulating since accident requiring asisstance and having a weight bearing. She states her ankle “ach
negative impact on daily activities. Pt went to the ER for the wound and Pain is rated 7 out of 10 with medication,
given tramadol for pain. Patient endorses the wound has gotten worse, She reports that over the past two days th
despite washing regualrly and applying fresh bandages twice daily. swollen and increasingly red; yesterday sh
the wound. She denies any odor from the
she has been wearing slip-ons. She repor
Fahrenheit last night. She denies recent il
unintentional weight loss over the month a
change in diet or level of activity.
Acetaminophen 500-1000 mg PO prn (he
Medications
Ibuprofen 600 mg PO TID prn (menstrual
the patient only has an inhaler which she uses as needed when having
difficulty breathoing due to asthma flare up. Pt is not on medications for Tramadol 50 mg PO TID prn (foot pain)
diabetes.
Albuterol 90 mcg/spray MDI 2 puffs Q4H p
Allergies Medications: Penicillin (rash).
Patient is allergic to penicillin with unknown reaction. Environmental: cats and dust (runny nose
increased asthma symptoms).
Asthma diagnosed at age 2 1/2. She uses
around cats and dust. She uses her inhale
exposed to cats three days ago and had t
positive relief of symptoms. She was last
school”.
Type 2 diabetes, diagnosed at age 24. Sh
she stopped three years ago, stating that
Medical History was overwhelming, taking pills and check
monitor her blood sugar. Last blood gluco
Ptatient has asthma and untreated diabetes. emergency room.
No surgeries.
Menarche, age 11. Identifies as heterosex
menstrual period 3 weeks ago. For the pa
weeks) with heavy bleeding lasting 9-10 d
oral contraceptives in the past. When sex
use condoms. Never tested for HIV/AIDS.
symptoms. Last tested for STIs four years
This study source was downloaded by 1827175 from cliffsnotes.com on 01-08-2026 20:14:57 GMT -06:00
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2026-01-09
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