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Exam (elaborations)

Comprehensive Assessment Completed Shadow Health | Turned In | score 99%

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Student Documentation Model Documentation Vitals BP 128/82, Temp 37.2, Pulse 78 Resps 15 SpO2 99%. • 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 Provides full name and verifies date of birth. 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 pleasant, well-groomed 28 year old AFrican American female wearing glasses to correct nearsightedness, 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. Reason for Visit Ms. Jones presents to clinic today for a preemployment physical. "I came in because I'm required to have a recent physical exam for the health insurance at my new job." Overview Transcript Subjective Data Collection Objective Data Collection Documentation Plan My Exam Self-Reflection

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Uploaded on
October 20, 2022
Number of pages
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Written in
2022/2023
Type
Exam (elaborations)
Contains
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