Documentation / Electronic Health Record SUMMARY

Documentation / Electronic Health Record  Documentation Vitals Student Documentation Model Documentation BP 128/82 P 78 RR 15 Temp 37.2 O2 99% Weight 84kg Height 5'6" BMI 29 BS 100 • 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 Ms. Jones is a pleasant 28 year old African American female who presents to the clinic today for a physical for employment. Pt's responses are appropriate, maintains eye contact throughout exam. Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment 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. Student Documentation Model Documentation General Survey Pt in no apparent distress, alert and oriented x 4, calm and cooperative, appropriately dressed wtih good hygiene. Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. She is well-nourished, welldeveloped, and dressed appropriately with good hygiene. Reason for Visit Pt states she needs an employment physical for a new job she will be beginning in two weeks. “I came in because I'm required to have a recent physical exam for the health insurance at my new job.” History of Present Illness Pt presents to the clininc for an employment physical that she will begin in two weeks. Pt denies any medical issues or concerns. Since last visit pt has had her annual PAP smear resulting diagnosis of PCOS with treatment using birth control, had her annual eye exam resulting in prescription glasses, pt states her diabetes is now controlled with medication and exercise. Pt. states she is eating healthier and has reduced her soda intake. Pt's perception of health and self is good. Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. She needs to obtain a preemployment physical prior to initiating employment. Today she denies any acute concerns. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. She has no 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. Student Documentation Model Documentation Medications Flovent 110mcg 2 puffs BID Albuterol 90mcg 2 puffs PRN Metformin 850mg PO BID Advil OTC regular strength PRN for cramps Yaz PO QD birth control • Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning) • Metformin, 850 mg PO BID (last use: this morning) • Drospirenone and ethinyl estradiol PO QD (last use: this morning) • Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three months ago) • Acetaminophen 500-1000 mg PO prn (headaches) • Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago) Allergies PCN- skin rash Cats- exacerbates asthma Dust-exacerbates asthma, itchy • Penicillin: rash • Denies food and latex allergies • Allergic to cats and dust. When she is exposed to allergens she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms. Medical History Asthma- diagnosed at 2 years old, uses daily and rescue inhaler, last exacerbation 3 months ago Diabetes- diagnosed at 24 years old, currently takes Metformin with gasiness upon inital use wtih no current side effects, pt taking BS QD, readings on average 90. HTN- controlled with diet and exercise Polycysic Ovarian Syndrome- diagnosed approximately 4 months ago, controlled with birth control, menstrual cycles normal and regular. Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she is around cats. Her last asthma exacerbation was three months ago, which she resolved with her inhaler. She was last hospitalized for asthma in high school. Never intubated. Type 2 diabetes, diagnosed at age 24. She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. She monitors her blood sugar once daily in the morning with average readings being around 90. She has a history of hypertension which normalized when she initiated diet and exercise. No surgeries. OB/GYN: Menarche, age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual. Student Documentation Model Documentation Never pregnant. Last menstrual period 2 weeks ago. Diagnosed with PCOS four months ago. For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. Has new male relationship, sexual contact not initiated. She plans to use condoms with sexual activity. Tested negative for HIV/AIDS and STIs four months ago. Health Maintenance Since last encounter at teh clinic pt has had an OBGYN exam approximately 4 months ago, pt had had an eye exam approximately 3 months ago. Pt states she is now exercising regularly, has been eating healthier, and has cut back on her caffiene and soda intake. Last Pap smear 4 months ago. Last eye exam three months ago. Last dental exam five months ago. PPD (negative) ~2 years ago. Immunizations: Tetanus booster was received within the past year, influenza is not current, and human papillomavirus has not been received. She reports that she believes she is up to date on childhood vaccines and received the meningococcal vaccine for college. Safety: Has smoke detectors in the home, wears seatbelt in car, and does not ride a bike. Uses sunscreen. Guns, having belonged to her dad, are in the home, locked in parent’s room. Family History Mother 50- high cholesterol and HTN Father- deceased at 58, high cholesterol, diabetes, and HTN Maternal grandmother- deeased at 73 from stroke, had HTN and high cholesterol Maternal grandfather- deceased at 80 from heart attack, had HTN and cholesterol Paternal grandmother 82- high cholesterol, HTN Paternal grandfather- deceased from colon cancer mid sixties, had • Mother: age 50, hypertension, elevated cholesterol • Father: deceased in car accident one year ago at age 58, hypertension, high cholesterol, and type 2 diabetes • Brother (Michael, 25): overweight • Sister (Britney, 14): asthma • Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol • Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol • Paternal grandmother: still living,