DOCUMENTATION COMPREHENSIVE ASSESSMENTT SHADOW HEALTH
, DOCUMENTATION COMPREHENSIVE ASSESSMENTT SHADOW HEALTH
Comprehensive Assessment Results | Turned In
Patient Assessment and Health Literacy - January 2019, NUR 325
Return to Assignment
Your Results Lab Pass
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Documentation
Objective Data Collection
Documentation Vitals
Plan My Exam
Student Documentation Model Documentation
Self-Reflection
• Height: 170 cm
• Weight: 84 kg
Vitals • BMI: 29.0
• Blood Glucose: 100
BP 128/82, Temp 37.2, Pulse 78 Resps 15 SpO2 • RR: 15
99%. • HR: 78
• BP:
• Pulse Ox: 99%
• Temperature: 99.0 F
Health History
Student Documentation Model Documentation
Ms. Jones is a pleasant, 28-year-old African
Identifying Data & Reliability American single woman who presents for a pre-
employment physical. She is the primary source of
Provides full name and verifies date of birth. 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 alert and oriented, seated upright on
Ms. Jones is a pleasant, well-groomed 28 year old the examination table, and is in no apparent
AFrican American female wearing glasses to correct distress. She is well-nourished, well-developed, and
nearsightedness, dressed appropriately with good hygiene.
employment physical.
Reason for Visit
Ms. Jones presents to clinic today for a pre-
, DOCUMENTATION COMPREHENSIVE ASSESSMENTT SHADOW HEALTH
Comprehensive Assessment Results | Turned In
Patient Assessment and Health Literacy - January 2019, NUR 325
Return to Assignment
Your Results Lab Pass
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Documentation
Objective Data Collection
Documentation Vitals
Plan My Exam
Student Documentation Model Documentation
Self-Reflection
• Height: 170 cm
• Weight: 84 kg
Vitals • BMI: 29.0
• Blood Glucose: 100
BP 128/82, Temp 37.2, Pulse 78 Resps 15 SpO2 • RR: 15
99%. • HR: 78
• BP:
• Pulse Ox: 99%
• Temperature: 99.0 F
Health History
Student Documentation Model Documentation
Ms. Jones is a pleasant, 28-year-old African
Identifying Data & Reliability American single woman who presents for a pre-
employment physical. She is the primary source of
Provides full name and verifies date of birth. 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 alert and oriented, seated upright on
Ms. Jones is a pleasant, well-groomed 28 year old the examination table, and is in no apparent
AFrican American female wearing glasses to correct distress. She is well-nourished, well-developed, and
nearsightedness, dressed appropriately with good hygiene.
employment physical.
Reason for Visit
Ms. Jones presents to clinic today for a pre-
