Documentation / Electronic Health Record
Documentation
Vitals
Student Documentation Model Documentation
• Height: 170 cm • Weight: 84 kg • BMI: 29.0 • Blood Glucose:
BP 128/82 P 78 RR 15 Temp 37.2 O2 99% Weight 84kg Height
100 • RR: 15 • HR: 78 • BP: • Pulse Ox: 99% •
5'6" BMI 29 BS 100
Temperature: 99.0 F
Health History
Student Documentation Model Documentation
Identifying Data & Reliability
Ms. Jones is a pleasant, 28-year-old African American single
woman who presents for a pre-employment physical. She is the
Ms. Jones is a pleasant 28 year old African American female who
primary source of the history. Ms. Jones offers information freely
presents to the clinic today for a physical for employment. Pt's
and without contradiction. Speech is clear and coherent. She
responses are appropriate, maintains eye contact throughout exam.
maintains eye contact throughout the interview.
, Student Documentation Model Documentation
General Survey
Ms. Jones is alert and oriented, seated upright on the examination
Pt in no apparent distress, alert and oriented x 4, calm and table, and is in no apparent distress. She is well-nourished, well-
cooperative, appropriately dressed wtih good hygiene. developed, and dressed appropriately with good hygiene.
Reason for Visit
“I came in because I'm required to have a recent physical exam for
Pt states she needs an employment physical for a new job she will
the health insurance at my new job.”
be beginning in two weeks.
Ms. Jones reports that she recently obtained employment at Smith,
History of Present Illness Stevens, Stewart, Silver & Company. She needs to obtain a pre-
employment physical prior to initiating employment. Today she
Pt presents to the clininc for an employment physical that she will denies any acute concerns. Her last healthcare visit was 4 months
begin in two weeks. Pt denies any medical issues or concerns. ago, when she received her annual gynecological exam at Shadow
Since last visit pt has had her annual PAP smear resulting diagnosis Health General Clinic. Ms. Jones states that the gynecologist
of PCOS with treatment using birth control, had her annual eye diagnosed her with polycystic ovarian syndrome and prescribed
exam resulting in prescription glasses, pt states her diabetes is now oral contraceptives at that visit, which she is tolerating well. She
controlled with medication and exercise. Pt. states she is eating has type 2 diabetes, which she is controlling with diet, exercise,
healthier and has reduced her soda intake. Pt's perception of health and metformin, which she just started 5 months ago. She has no
and self is good. 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.
Documentation
Vitals
Student Documentation Model Documentation
• Height: 170 cm • Weight: 84 kg • BMI: 29.0 • Blood Glucose:
BP 128/82 P 78 RR 15 Temp 37.2 O2 99% Weight 84kg Height
100 • RR: 15 • HR: 78 • BP: • Pulse Ox: 99% •
5'6" BMI 29 BS 100
Temperature: 99.0 F
Health History
Student Documentation Model Documentation
Identifying Data & Reliability
Ms. Jones is a pleasant, 28-year-old African American single
woman who presents for a pre-employment physical. She is the
Ms. Jones is a pleasant 28 year old African American female who
primary source of the history. Ms. Jones offers information freely
presents to the clinic today for a physical for employment. Pt's
and without contradiction. Speech is clear and coherent. She
responses are appropriate, maintains eye contact throughout exam.
maintains eye contact throughout the interview.
, Student Documentation Model Documentation
General Survey
Ms. Jones is alert and oriented, seated upright on the examination
Pt in no apparent distress, alert and oriented x 4, calm and table, and is in no apparent distress. She is well-nourished, well-
cooperative, appropriately dressed wtih good hygiene. developed, and dressed appropriately with good hygiene.
Reason for Visit
“I came in because I'm required to have a recent physical exam for
Pt states she needs an employment physical for a new job she will
the health insurance at my new job.”
be beginning in two weeks.
Ms. Jones reports that she recently obtained employment at Smith,
History of Present Illness Stevens, Stewart, Silver & Company. She needs to obtain a pre-
employment physical prior to initiating employment. Today she
Pt presents to the clininc for an employment physical that she will denies any acute concerns. Her last healthcare visit was 4 months
begin in two weeks. Pt denies any medical issues or concerns. ago, when she received her annual gynecological exam at Shadow
Since last visit pt has had her annual PAP smear resulting diagnosis Health General Clinic. Ms. Jones states that the gynecologist
of PCOS with treatment using birth control, had her annual eye diagnosed her with polycystic ovarian syndrome and prescribed
exam resulting in prescription glasses, pt states her diabetes is now oral contraceptives at that visit, which she is tolerating well. She
controlled with medication and exercise. Pt. states she is eating has type 2 diabetes, which she is controlling with diet, exercise,
healthier and has reduced her soda intake. Pt's perception of health and metformin, which she just started 5 months ago. She has no
and self is good. 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.
