Shadow Health Tina Jones Respiratory Documentation
Shadow Health Tina Jones Respiratory
Documentation Documentation / Electronic
Health Record
Document: Provider Notes
Student Documentation Model Documentation
HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of shortness of
breath and wheezing following a near asthma attack that she had two days ago. She reports that she was at her cousin’s
house and was exposed to cats which triggered her asthma symptoms. At the time of the incident she notes that her wheezes
were a 6/10 severity and her shortness of breath was a 7- 8/10 severity and lasted five minutes. She did not experience any
chest pain or allergic symptoms. At that time she used her albuterol inhaler and her symptoms decreased although they did
not completely resolve. Since that incident she notes that she has had 10 episodes of wheezing and has shortness of breath
approximately every four hours. Her last episode of shortness of breath was this morning before coming to clinic. She notes
that her current symptoms seem to be worsened by lying flat and movement and are accompanied by a non-productive
Subjectiv cough. She awakens with night- time shortness of breath twice per night. She complains that her current symptoms are
beginning to interfere with her daily activities and she is concerned that her albuterol inhaler seems to be less effective than
e xxx previous. Currently she states that her breathing is normal. Diagnosed with asthma at age 2.5 years. She has no recent use of
spirometry, does not use a peak flow, does not record attacks, and does not have a home nebulizer or vaporizer. She has been
hospitalized five times for asthma, last at age 16. She has never been intubated for her asthma. She does not have a current
pulmonologist or allergist. Social History: She is not aware of any environmental exposures or irritants at her job or home. She
changes her sheets weekly and denies dust/mildew at her home. She uses a hypoallergenic pillow cover and her mattress is
one year old. She denies current use of tobacco, alcohol, and illicit drugs. She did smoke marijuana for 5 or 6 years, her last
use was at age 21 years. She does not exercise. Review of Systems: General: Denies changes in weight, fatigue, weakness,
fever, chills, and night sweats. • Nose/Sinuses: Denies rhinorrhea with this episode. Denies stuffiness, sneezing, itching,
previous allergy, epistaxis, or sinus pressure. • Gastrointestinal: No changes in appetite, no nausea, no vomiting, no symptoms
of GERD or abdominal pain • Respiratory: Complains of shortness of breath and cough as above. Denies sputum, hemoptysis,
pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization was age 16, last chest XR
was age 16.
General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented and
Objectiv sitting upright on exam table. She maintains eye contact throughout interview and examination. • Respiratory: Chest
expansion is symmetrical with respirations. Normal fremitus, symmetric bilaterally. Chest resonant to percussion; no dullness.
e xxxx Bilateral expiratory wheezes in posterior lower lobes. Bilateral muffled words with notable expiratory wheezes in posterior
lower lobes. No crackles. In office spirometry: FVC 3.91 L, FEV1/FVC ratio 80.56%. SpO2: 97%.
Assessme
Asthma exacerbation
nt xxx
Encourage Ms. Jones to continue to monitor symptoms and log her episodes of asthma symptoms and wheezing with
associated factors and bring log to next visit. • Obtain office oxygen saturation. • Order PFTs to be completed after
Plan
exacerbation to have baseline available for future comparison. • Encourage to wash bedding and consider dust mite covers to
xxxx decrease allergic nighttime symptoms. • NMT in office x 1. • Educate to increase intake of water and other fluids. • Educate
Ms. Jones on when to seek emergent care including episodes of chest pain or shortness of breath unrelieved by rest,
worsening asthma symptoms or wheezing, or the sense that rescue inhaler is not helping. • Revisit clinic in 2-4 weeks for
follow up and evaluation.
Respiratory
Assessment Asked
about asthma
Reports having
asthma
Reports asthma exacerbations
Asked about severity of
asthma
Reports asthma exacerbations occur up to 2 times
a week Reports asthma exacerbations last
around five minutes Asked most recent asthma
exacerbation
Reports last exacerbation was three days ago
Reports last exacerbation around cats at cousin's
house Asked about asthma triggers
Reports cat allergy as asthma
trigger Reports dust as asthma
trigger Denies asthma
problems at work Denies
asthma problems at home
,Shadow Health Tina Jones Respiratory Documentation
Asked asthma management
Reports inhaler
Asked about asthma
medication Reports albuterol
inhaler (Proventil)
Reports last inhaler use was three days ago
Reports using inhaler no more than 2 times per
week Asked about number of puffs when using
asthma inhaler Reports recommended dose is 1-
3 puffs as needed Reports typically taking 2 puffs
Reports sometimes needing 3 puffs to control
symptoms Asked exacerbation symptoms
Reports chest tightness during
exacerbation Reports wheezing during
exacerbation
Reports shortness of breath during
exacerbation Denies coughing during
exacerbation
Denies chest pain during
exacerbation Denies painful
breathing
Asked current breathing
Denies current breathing problems
,Shadow Health Tina Jones Respiratory Documentation
Asked cough history
Reports only coughing when she has a
cold Denies coughing up blood
Asked about
sputum Denies
sputum
Asked about respiratory illness history besides
asthma Denies history of bronchitis
Denies history of pneumonia
Denies history of emphysema
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Followed up on asthma diagnosis
Reports specific age of diagnosis is 2.5
years old Asked about seeing an asthma
specialist
Reports not seeing asthma doctor in two
years Asked about past hospitalizations
Reports past hospitalizations for asthma
Reports five past hospitalizations for
asthma Reports most recent
hospitalization at age 16
Reports hospital treatment was usually steroids and a
nebulizer Asked about general allergies
Reports allergy to cats
Followed up on allergy symptoms
Reports sneezing, itchy eyes, and
wheezing Asked about allergy treatment
Reports avoiding cats when
possible Reports using inhaler
Reports showering
Asked about tobacco
use
Denies currently smoking
tobacco Denies history of
smoking tobacco Denies
vaping
Asked about marijuana use
Reports past recreational marijuana
smoking Followed up on marijuana
Reports smoking marijuana for 5 or 6 years
Reports stopped smoking marijuana 6 or 7 years ago
Reports stopping because of health reasons and waning
interest Asked about secondhand smoke
Denies secondhand smoke
exposure Upgrade to remove
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Asked family history of asthma
Reports sister has asthma
Asked family history of other respiratory
illness Denies family history of
respiratory illness Asked family tobacco
use
Denies family history of tobacco use
Asked about family history of lung
cancer Denies family history of lung
cancer
, Shadow Health Tina Jones Respiratory Documentation
Inspected chest
Symmetric
No visible abnormal findings
Palpated chest expansion
Equal bilaterally
Palpated tactile fremitus
Equal bilaterally
Expected fremitus
Percussed chest wall
All areas resonant
No areas of dullness
Auscultated breath sounds
Present in all areas
Wheezing - posterior right and left lower lobes
Auscultated for bronchophony
Negative
Patient Exam - Vital Signs:
Height: 170 cm, Weight: 90 kg, BMI: 31, Random blood glucose: 238, Temperature: 102.4° F, Blood pressure: 138/90 mmHg, Heart rate: 90, Respiratory rate: 18, O2 sat: 98%
Patient Exam - Interview:
...
Student: Hello, my name is Catlain, I am your nurse today.
Tina Jones: Hey.
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Student: Can you confirm your name?
Tina Jones: Tina Jones:.
Student: Why did you come in today?
Tina Jones: I got this scrape on my foot a while ago, and it got really infected. It's killing me.
Student: What additional symptoms have you experienced?
Tina Jones: I mean, it's all red and swollen, and there's pus, it feels hot, it hurts like hell... It's got all that going on.
Student: Can you rate your current pain level on a scale of 0 to 10?
Tina Jones: ...Like a 7. It hurts a lot, but whatever pain med the ER gave me is helping a little bit.
Student: Please describe the pain.
Tina Jones: It's throbbing and like, sharp if I try to put weight on it.
Student: How did you hurt your foot?
Tina Jones: I was changing a light bulb, and I had to use our little stepstool to reach it. My foot slid off the bottom step and it got all scraped up. I didn't realize how sharp the edge was!
Student: Has your foot been draining any liquids?
Tina Jones: Yeah, there's definitely pus.
Shadow Health Tina Jones Respiratory
Documentation Documentation / Electronic
Health Record
Document: Provider Notes
Student Documentation Model Documentation
HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of shortness of
breath and wheezing following a near asthma attack that she had two days ago. She reports that she was at her cousin’s
house and was exposed to cats which triggered her asthma symptoms. At the time of the incident she notes that her wheezes
were a 6/10 severity and her shortness of breath was a 7- 8/10 severity and lasted five minutes. She did not experience any
chest pain or allergic symptoms. At that time she used her albuterol inhaler and her symptoms decreased although they did
not completely resolve. Since that incident she notes that she has had 10 episodes of wheezing and has shortness of breath
approximately every four hours. Her last episode of shortness of breath was this morning before coming to clinic. She notes
that her current symptoms seem to be worsened by lying flat and movement and are accompanied by a non-productive
Subjectiv cough. She awakens with night- time shortness of breath twice per night. She complains that her current symptoms are
beginning to interfere with her daily activities and she is concerned that her albuterol inhaler seems to be less effective than
e xxx previous. Currently she states that her breathing is normal. Diagnosed with asthma at age 2.5 years. She has no recent use of
spirometry, does not use a peak flow, does not record attacks, and does not have a home nebulizer or vaporizer. She has been
hospitalized five times for asthma, last at age 16. She has never been intubated for her asthma. She does not have a current
pulmonologist or allergist. Social History: She is not aware of any environmental exposures or irritants at her job or home. She
changes her sheets weekly and denies dust/mildew at her home. She uses a hypoallergenic pillow cover and her mattress is
one year old. She denies current use of tobacco, alcohol, and illicit drugs. She did smoke marijuana for 5 or 6 years, her last
use was at age 21 years. She does not exercise. Review of Systems: General: Denies changes in weight, fatigue, weakness,
fever, chills, and night sweats. • Nose/Sinuses: Denies rhinorrhea with this episode. Denies stuffiness, sneezing, itching,
previous allergy, epistaxis, or sinus pressure. • Gastrointestinal: No changes in appetite, no nausea, no vomiting, no symptoms
of GERD or abdominal pain • Respiratory: Complains of shortness of breath and cough as above. Denies sputum, hemoptysis,
pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization was age 16, last chest XR
was age 16.
General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented and
Objectiv sitting upright on exam table. She maintains eye contact throughout interview and examination. • Respiratory: Chest
expansion is symmetrical with respirations. Normal fremitus, symmetric bilaterally. Chest resonant to percussion; no dullness.
e xxxx Bilateral expiratory wheezes in posterior lower lobes. Bilateral muffled words with notable expiratory wheezes in posterior
lower lobes. No crackles. In office spirometry: FVC 3.91 L, FEV1/FVC ratio 80.56%. SpO2: 97%.
Assessme
Asthma exacerbation
nt xxx
Encourage Ms. Jones to continue to monitor symptoms and log her episodes of asthma symptoms and wheezing with
associated factors and bring log to next visit. • Obtain office oxygen saturation. • Order PFTs to be completed after
Plan
exacerbation to have baseline available for future comparison. • Encourage to wash bedding and consider dust mite covers to
xxxx decrease allergic nighttime symptoms. • NMT in office x 1. • Educate to increase intake of water and other fluids. • Educate
Ms. Jones on when to seek emergent care including episodes of chest pain or shortness of breath unrelieved by rest,
worsening asthma symptoms or wheezing, or the sense that rescue inhaler is not helping. • Revisit clinic in 2-4 weeks for
follow up and evaluation.
Respiratory
Assessment Asked
about asthma
Reports having
asthma
Reports asthma exacerbations
Asked about severity of
asthma
Reports asthma exacerbations occur up to 2 times
a week Reports asthma exacerbations last
around five minutes Asked most recent asthma
exacerbation
Reports last exacerbation was three days ago
Reports last exacerbation around cats at cousin's
house Asked about asthma triggers
Reports cat allergy as asthma
trigger Reports dust as asthma
trigger Denies asthma
problems at work Denies
asthma problems at home
,Shadow Health Tina Jones Respiratory Documentation
Asked asthma management
Reports inhaler
Asked about asthma
medication Reports albuterol
inhaler (Proventil)
Reports last inhaler use was three days ago
Reports using inhaler no more than 2 times per
week Asked about number of puffs when using
asthma inhaler Reports recommended dose is 1-
3 puffs as needed Reports typically taking 2 puffs
Reports sometimes needing 3 puffs to control
symptoms Asked exacerbation symptoms
Reports chest tightness during
exacerbation Reports wheezing during
exacerbation
Reports shortness of breath during
exacerbation Denies coughing during
exacerbation
Denies chest pain during
exacerbation Denies painful
breathing
Asked current breathing
Denies current breathing problems
,Shadow Health Tina Jones Respiratory Documentation
Asked cough history
Reports only coughing when she has a
cold Denies coughing up blood
Asked about
sputum Denies
sputum
Asked about respiratory illness history besides
asthma Denies history of bronchitis
Denies history of pneumonia
Denies history of emphysema
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Followed up on asthma diagnosis
Reports specific age of diagnosis is 2.5
years old Asked about seeing an asthma
specialist
Reports not seeing asthma doctor in two
years Asked about past hospitalizations
Reports past hospitalizations for asthma
Reports five past hospitalizations for
asthma Reports most recent
hospitalization at age 16
Reports hospital treatment was usually steroids and a
nebulizer Asked about general allergies
Reports allergy to cats
Followed up on allergy symptoms
Reports sneezing, itchy eyes, and
wheezing Asked about allergy treatment
Reports avoiding cats when
possible Reports using inhaler
Reports showering
Asked about tobacco
use
Denies currently smoking
tobacco Denies history of
smoking tobacco Denies
vaping
Asked about marijuana use
Reports past recreational marijuana
smoking Followed up on marijuana
Reports smoking marijuana for 5 or 6 years
Reports stopped smoking marijuana 6 or 7 years ago
Reports stopping because of health reasons and waning
interest Asked about secondhand smoke
Denies secondhand smoke
exposure Upgrade to remove
ads
Only $35.99/year
Asked family history of asthma
Reports sister has asthma
Asked family history of other respiratory
illness Denies family history of
respiratory illness Asked family tobacco
use
Denies family history of tobacco use
Asked about family history of lung
cancer Denies family history of lung
cancer
, Shadow Health Tina Jones Respiratory Documentation
Inspected chest
Symmetric
No visible abnormal findings
Palpated chest expansion
Equal bilaterally
Palpated tactile fremitus
Equal bilaterally
Expected fremitus
Percussed chest wall
All areas resonant
No areas of dullness
Auscultated breath sounds
Present in all areas
Wheezing - posterior right and left lower lobes
Auscultated for bronchophony
Negative
Patient Exam - Vital Signs:
Height: 170 cm, Weight: 90 kg, BMI: 31, Random blood glucose: 238, Temperature: 102.4° F, Blood pressure: 138/90 mmHg, Heart rate: 90, Respiratory rate: 18, O2 sat: 98%
Patient Exam - Interview:
...
Student: Hello, my name is Catlain, I am your nurse today.
Tina Jones: Hey.
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Only $35.99/year
Student: Can you confirm your name?
Tina Jones: Tina Jones:.
Student: Why did you come in today?
Tina Jones: I got this scrape on my foot a while ago, and it got really infected. It's killing me.
Student: What additional symptoms have you experienced?
Tina Jones: I mean, it's all red and swollen, and there's pus, it feels hot, it hurts like hell... It's got all that going on.
Student: Can you rate your current pain level on a scale of 0 to 10?
Tina Jones: ...Like a 7. It hurts a lot, but whatever pain med the ER gave me is helping a little bit.
Student: Please describe the pain.
Tina Jones: It's throbbing and like, sharp if I try to put weight on it.
Student: How did you hurt your foot?
Tina Jones: I was changing a light bulb, and I had to use our little stepstool to reach it. My foot slid off the bottom step and it got all scraped up. I didn't realize how sharp the edge was!
Student: Has your foot been draining any liquids?
Tina Jones: Yeah, there's definitely pus.
