NR-509 Advanced Physical Assessment-Shadow Health Tina Jones Documentation-EHR

NR-509 Advanced Physical Assessment-Shadow Health Tina Jones Documentation-EHR Document: Provider Notes Student Documentation Model Documentation Health History Tips and Tricks Lifespan Self-Reflection Identifying Data & Reliability Ms. Tina Jones 28 year old , African American, single who presents to the clinic with concerns of her recent right foot injury. Ms. Jones is pleasant and good historian. Ms. Jones is a pleasant, 28-year-old obese African American s woman who presents to establish care and with a recent right f injury. She is the primary source of the history. Ms. Jones offer information freely and without contradiction. Speech is clear an coherent. She maintains eye contact throughout the interview. General Survey Ms. Jones is alert and oriented, no apparent distress, properly groomed. Ms. Jones is alert and oriented, seated upright on the examina table, and is in no apparent distress. She is well-nourished, we developed, and dressed appropriately with good hygiene. Chief Complaint Patient reports that she sustained a scraped at the plantar surface of her foot. The wound is draining with pus, no fouly smell but the pain is bothering her, and the pain got worse of the last 2 days. Patient states that the "pain is killing me". “I got this scrape on my foot a while ago, and I thought it would up on its own, but now it's looking pretty nasty. And the pain is killing me!” History Of Present Illness Patient states that she was doing down the back steps. She tripped, and caught the railing, and kind of turned her ankle. She scraped up her foot on the edge of the step. She went to the ER with concerns that she fracture her ankle. While in ER they xray the ankle and the foot , the result shows negative for fracture. She was sent with prescription of tramadol. Patient is taking the pain medications three times a day. Patient states the pain is relieved by medication but only for a few hours, and then she starts feeling the throbbing pain. Patient states that she clean the wound with soap and water and put neosporin and wrap it with bandage twice a day. Ms. Jones states that the wound get worst. The discharge in the wound is oozing, but clear drainage, and the wound feels warm and get more swollen. She reported to having a fever with a temperature of 102 last night. Reported that about a month ago she lose weight 10lbs without trying. No changes of diet