NR 509 Shadow Health Physical Assessment: Week 1 Shadow Health
History Assignment.
Document: Provider Notes
Student Response Model Documentation
Ms. Jones is a pleasant, 28-year-old obese
African American single woman who
Identifying Tina Jones age: 28 African American presents to establish care and with a recent
Data & female patient herself, seems reliable right foot injury. She is the primary source
Reliability supervisor at Mid-American Copy & of the history. Ms. Jones offers
Ship information freely and without
contradiction. Speech is clear and
coherent. She maintains eye contact
throughout the interview.
Tina is a 28 year old African Ms. Jones is alert and oriented, seated
General upright on the examination table, and is in
American female that appears healthy
no apparent distress. She is well-
Survey and stated age. Alert, oriented, and
nourished, well-developed, and dressed
cooperative. No signs of distress.
appropriately with good hygiene.
“I got this scrape on my foot a while ago,
Chief "I got this scrape on my foot a while and I thought it would heal up on its own,
Complaint ago...and the pain is killing me!" but now it's looking pretty nasty. And the
pain is killing me!”
History Of First noticed scrape on right foot two Ms. Jones reports that a week ago she
Present days ago. Tripped and fell down tripped while walking on concrete stairs
Illness steps, scraped foot on the edge of the outside, twisting her right ankle and
step. Sharp, throbbing pain rated a 7 scraping the ball of her foot. She sought
on 0-10 scale. White drainage. Unable care in a local emergency department
to bear weight on right foot and has where she had x-rays that were negative;
missed two days of work. No chills or she was treated with tramadol for pain. She
fever noted. Reports temperature of has been cleansing the site twice a day.
102 last night. She has been applying antibiotic ointment
and a bandage. She reports that ankle
swelling and pain have resolved but that
the bottom of the foot is increasingly
painful. The pain is described as
“throbbing” and “sharp” with weight
bearing. She states her ankle “ached” but is
resolved. Pain is rated 7 out of 10 after a
recent dose of tramadol. Pain is rated 9
History Assignment.
Document: Provider Notes
Student Response Model Documentation
Ms. Jones is a pleasant, 28-year-old obese
African American single woman who
Identifying Tina Jones age: 28 African American presents to establish care and with a recent
Data & female patient herself, seems reliable right foot injury. She is the primary source
Reliability supervisor at Mid-American Copy & of the history. Ms. Jones offers
Ship information freely and without
contradiction. Speech is clear and
coherent. She maintains eye contact
throughout the interview.
Tina is a 28 year old African Ms. Jones is alert and oriented, seated
General upright on the examination table, and is in
American female that appears healthy
no apparent distress. She is well-
Survey and stated age. Alert, oriented, and
nourished, well-developed, and dressed
cooperative. No signs of distress.
appropriately with good hygiene.
“I got this scrape on my foot a while ago,
Chief "I got this scrape on my foot a while and I thought it would heal up on its own,
Complaint ago...and the pain is killing me!" but now it's looking pretty nasty. And the
pain is killing me!”
History Of First noticed scrape on right foot two Ms. Jones reports that a week ago she
Present days ago. Tripped and fell down tripped while walking on concrete stairs
Illness steps, scraped foot on the edge of the outside, twisting her right ankle and
step. Sharp, throbbing pain rated a 7 scraping the ball of her foot. She sought
on 0-10 scale. White drainage. Unable care in a local emergency department
to bear weight on right foot and has where she had x-rays that were negative;
missed two days of work. No chills or she was treated with tramadol for pain. She
fever noted. Reports temperature of has been cleansing the site twice a day.
102 last night. She has been applying antibiotic ointment
and a bandage. She reports that ankle
swelling and pain have resolved but that
the bottom of the foot is increasingly
painful. The pain is described as
“throbbing” and “sharp” with weight
bearing. She states her ankle “ached” but is
resolved. Pain is rated 7 out of 10 after a
recent dose of tramadol. Pain is rated 9
