NR 509 Shadow Health Documentation / Electronic Health Record 2017

NR 509 Shadow Health Documentation / Electronic Health Record 2017 Documentation / Electronic Health Record Vitals Student Documentation Model Documentation 128/82 mm Hg (97.3 MAP) HP 78 99% SpO2 98.9 degrees F FVC 3.91 L FEV1 3.15 L FEV1/FVC - 0.81 • 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 Health History Student Documentation Model Documentation Identifying Data & Reliability Able to state name and date of birth that matches EHR records. Oriented x3. (For the record, I did stop before starting asking questions. There should be a lapse in time. I was documenting) Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a preemployment physical. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview. General Survey Ms. Jones is a 28 year old obese, African American woman who is clearly able to keep up with her ADLs. Her hair is braided, her clothes are clean, she seems to be able to keep up with hygiene. She does not seem to be in any acute distress. Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene