6/3/2021 HEENT (Unlimited Attempts) with SOAP Note | Completed | Shadow Health
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HEENT (Unlimited Attempts) with SOAP Note Results | Completed
Advanced Health Assessment - Clinicals - May 2021, nur_6001
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Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Document: Provider Notes
Objective Data Collection
Document: Provider Notes
Education & Empathy
Documentation
Student Documentation Model Documentation
6/3/2021 HEENT (Unlimited Attempts) with SOAP Note | Completed | Shadow Health
Support
Student Documentation Model Documentation
https://app.shadowhealth.com/assignment_attempts/9898576 1/4
CC: “My throat is sore and itchy and my nose won’t stop runnin
HPI: Ms. Jones is a pleasant 28-year-old African American wom
who presented to the clinic with complaints of sore, itchy throat
Subjective eyes, and runny nose for the last week. She states that these
symptoms started spontaneously and have been constant in na
Chief Complaint: "throat has been sore and itchy and nose won't stop
She does not note any specific aggravating symptoms, but stat
running."
her throat pain seems to be worse in the morning. She rates he
HPI: Ms. Jones is a 28 year old african american female. who
throat pain as 4/10 and her throat itchiness as 5/10. She has tre
presented to the clinic with complaints of a sore and itchy throat, itchy
her throat pain with occasional throat lozenges which has “help
eyes and runny nose which started 7 days ago. States the symptoms
little”. She states that she has some soreness when swallowing
started spontanously with moderate throat symptoms that "doesn't go
otherwise no other associated symptoms. She states that her n
away" and itchy eyes and runny nose that "aren't worse but
“runs all day” and is clear discharge. She has not attempted an
aggravating." Patient states throat pain is worse in morning and rates
treatment for her nasal symptoms. She states that her eyes are
pain 4/10. Patient rates throat itchiness 5/10. Patient states she has
constantly itchy and she has not attempted any eye specific
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