10/16/24, 12:35 Shadow Health Tina Jones Comprehensive Results Documentation
PM Resul…
Your Results Lab Pass
Overvie
Documentation / Electronic Health Record
w
Transcri Documentation
pt
Subjective Data
Vitals
Collection Objective Student Documentation Model Documentation
Data Collection
Documentation
Plan My Exam
Video
Tutorial
•Height: 170 cm
•Weight: 84 kg
•BMI: 29.0
Vitals •Blood Glucose: 100
•RR: 15
T: 37.2 C / 98.96 F. BP: 128/82 nnHg. HR: 78. R: 15.
•HR: 78
SpO2: 99%
•BP:
•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
single w who presents for a pre-employment
Patient is in positive mood, alert and physical. She is the primar source of the history. Ms.
oriented x3 Jones offers information freely and w contradiction.
Speech is clear and coherent. She maintains eye
contact throughout the interview.
General Survey Ms. Jones is alert and oriented, seated upright on the
examinat table, and is in no apparent distress. She is
Patient appears stated age and in good
well-nourished, we developed, and dressed
health.
appropriately with good hygiene.
about:blan 1/
k 6
, 10/16/24, 12:35 Shadow Health Tina Jones Comprehensive Results Documentation
PM Resul…
Health® │ Digital Clinical Experiences™ from Elsevier
Student Documentation Model Documentation
Reason for Visit
"I came in because I'm required to have a recent
Employment physical exam the health insurance at my new job."
Physical
Ms. Jones reports that she recently obtained
employment at S Stevens, Stewart, Silver &
Company. She needs to obtain a pre employment
physical prior to initiating employment. Today she
History of Present any acute concerns. Her last healthcare visit was 4
Illness months ago when she received her annual
gynecological exam at Shadow General Clinic. Ms.
None reported. Jones states that the gynecologist diagnos with
polycystic ovarian syndrome and prescribed oral
contracep at that visit, which she is tolerating well.
She has type 2 diabete which she is controlling with
diet, exercise, and metformin, whic just started 5
months ago. She has no medication side effects time.
She states that she feels healthy, is taking better care
of h than in the past, and is looking forward to
beginning the new jo
•Metformin, 850 mg PO BID (last use: this morning)
Medications •Drospirenone and ethinyl estradiol PO QD (last use: this
morn
Metaformin (Diabetes); Albuterol (Asthma); Provental •Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn (last use:
(Asthma) yest
•Acetaminophen 500-1000 mg PO prn (headaches)
•Ibuprofen 600 mg PO TID prn (menstrual cramps:
last taken weeks ago)
Allergies •Penicillin: rash
•Denies food and latex allergies
Cats and •Allergic to cats and dust. When she is exposed to
Penicillin allergens s states that she has runny nose, itchy and
swollen eyes, and increased asthma symptoms.
Asthma diagnosed at age 2 1/2. She uses her
albuterol inhaler she experiences exacerbations, such
as around dust or cats. H asthma exacerbation was
yesterday, which she resolved with h inhaler. She
was last hospitalized for asthma in high school. Ne
intubated. Type 2 diabetes, diagnosed at age 24. She
Medical History began metformin 5 months ago and initially had
some gastrointestinal effects which have since
Diabetes Mellitis diagnoed two year ago; Wound dissipated. She monitors her blood su once daily in
healing on right plantar foot; Asthma since childhood the morning with average readings being around She
has a history of hypertension which normalized when
she initiated diet and exercise. No surgeries. OB/GYN:
Menarche, a First sexual encounter at age 18, sex
with men, identifies as heterosexual. Never pregnant.
Last menstrual period 2 weeks a Diagnosed with PCOS
four months ago. For the past four mont (after
initiating Yaz) cycles regular (every 4 weeks) with
modera bleeding lasting 5 days. Has new male
relationship, sexual con not initiated. She plans to
use condoms with sexual activity. Tes negative for
HIV/AIDS and STIs four months ago.
Last Pap smear 4 months ago. Last eye exam three
months ag Last dental exam five months ago. PPD
(negative) ~2 years ag Immunizations: Tetanus
Health Maintenance booster was received within the past y influenza is
not current, and human papillomavirus has been
On Diabetes safe diet plan as per
received. She reports that she believes she is up to
nutritionist.
date on ch vaccines and received the meningococcal
vaccine for college. Has smoke detectors in the
home, wears seatbelt in car, and d not ride a bike.
Uses sunscreen. Guns, having belonged to her are in
the home, locked in parent’s room.
2/6
about:blan 2/
k 6
PM Resul…
Your Results Lab Pass
Overvie
Documentation / Electronic Health Record
w
Transcri Documentation
pt
Subjective Data
Vitals
Collection Objective Student Documentation Model Documentation
Data Collection
Documentation
Plan My Exam
Video
Tutorial
•Height: 170 cm
•Weight: 84 kg
•BMI: 29.0
Vitals •Blood Glucose: 100
•RR: 15
T: 37.2 C / 98.96 F. BP: 128/82 nnHg. HR: 78. R: 15.
•HR: 78
SpO2: 99%
•BP:
•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
single w who presents for a pre-employment
Patient is in positive mood, alert and physical. She is the primar source of the history. Ms.
oriented x3 Jones offers information freely and w contradiction.
Speech is clear and coherent. She maintains eye
contact throughout the interview.
General Survey Ms. Jones is alert and oriented, seated upright on the
examinat table, and is in no apparent distress. She is
Patient appears stated age and in good
well-nourished, we developed, and dressed
health.
appropriately with good hygiene.
about:blan 1/
k 6
, 10/16/24, 12:35 Shadow Health Tina Jones Comprehensive Results Documentation
PM Resul…
Health® │ Digital Clinical Experiences™ from Elsevier
Student Documentation Model Documentation
Reason for Visit
"I came in because I'm required to have a recent
Employment physical exam the health insurance at my new job."
Physical
Ms. Jones reports that she recently obtained
employment at S Stevens, Stewart, Silver &
Company. She needs to obtain a pre employment
physical prior to initiating employment. Today she
History of Present any acute concerns. Her last healthcare visit was 4
Illness months ago when she received her annual
gynecological exam at Shadow General Clinic. Ms.
None reported. Jones states that the gynecologist diagnos with
polycystic ovarian syndrome and prescribed oral
contracep at that visit, which she is tolerating well.
She has type 2 diabete which she is controlling with
diet, exercise, and metformin, whic just started 5
months ago. She has no medication side effects time.
She states that she feels healthy, is taking better care
of h than in the past, and is looking forward to
beginning the new jo
•Metformin, 850 mg PO BID (last use: this morning)
Medications •Drospirenone and ethinyl estradiol PO QD (last use: this
morn
Metaformin (Diabetes); Albuterol (Asthma); Provental •Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn (last use:
(Asthma) yest
•Acetaminophen 500-1000 mg PO prn (headaches)
•Ibuprofen 600 mg PO TID prn (menstrual cramps:
last taken weeks ago)
Allergies •Penicillin: rash
•Denies food and latex allergies
Cats and •Allergic to cats and dust. When she is exposed to
Penicillin allergens s states that she has runny nose, itchy and
swollen eyes, and increased asthma symptoms.
Asthma diagnosed at age 2 1/2. She uses her
albuterol inhaler she experiences exacerbations, such
as around dust or cats. H asthma exacerbation was
yesterday, which she resolved with h inhaler. She
was last hospitalized for asthma in high school. Ne
intubated. Type 2 diabetes, diagnosed at age 24. She
Medical History began metformin 5 months ago and initially had
some gastrointestinal effects which have since
Diabetes Mellitis diagnoed two year ago; Wound dissipated. She monitors her blood su once daily in
healing on right plantar foot; Asthma since childhood the morning with average readings being around She
has a history of hypertension which normalized when
she initiated diet and exercise. No surgeries. OB/GYN:
Menarche, a First sexual encounter at age 18, sex
with men, identifies as heterosexual. Never pregnant.
Last menstrual period 2 weeks a Diagnosed with PCOS
four months ago. For the past four mont (after
initiating Yaz) cycles regular (every 4 weeks) with
modera bleeding lasting 5 days. Has new male
relationship, sexual con not initiated. She plans to
use condoms with sexual activity. Tes negative for
HIV/AIDS and STIs four months ago.
Last Pap smear 4 months ago. Last eye exam three
months ag Last dental exam five months ago. PPD
(negative) ~2 years ag Immunizations: Tetanus
Health Maintenance booster was received within the past y influenza is
not current, and human papillomavirus has been
On Diabetes safe diet plan as per
received. She reports that she believes she is up to
nutritionist.
date on ch vaccines and received the meningococcal
vaccine for college. Has smoke detectors in the
home, wears seatbelt in car, and d not ride a bike.
Uses sunscreen. Guns, having belonged to her are in
the home, locked in parent’s room.
2/6
about:blan 2/
k 6
