CC Pain in lower back. “Tweaked” it while lifting a box. HPI: include all the information regarding the CC using the OLDCART format. If the CC was “Unintentional weight loss”, the OLDCART for the HPI might look like the following example: Onset: 3 days ago Location: Bilateral lower back. Does not radiate. Duration: 3 days Characteristics: Described as an ache, constant, does not radiate. Pain at its worst when she first injured her back stats 6-7/10. Current pain 5/10. Aggravatin...

Tina Jones Seen 1 month ago to establish care. S. CC “My throat has been sore…and itchy. And my nose won’t stop running. These symptoms are driving me nuts.” HPI: include all the information regarding the CC using the OLDCART format. If the CC was “Unintentional weight loss”, the OLDCART for the HPI might look like the following example: Onset: “2-7 days” Location: Throat, 4/10 Duration: Steady weight loss, 3-5 pounds per week Characteristics: “sore” throat…”jus...

NUR 509 Neurological Completed Shadow Health Documentation GRADED A+ /NUR 509 Neurological Completed Shadow Health Documentation GRADED A+

Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Comprehensive Assessment

nformation the patient or patient representative told you. Initials: T. J. Age: 28 Gender: Female Height: 170cm Weight: 86kg BMI: 30.8 BP: 140/81 BG: 224 RR: 20 HR: 89 Temp: 98.5 SPO2: 97% Pain (1-10): Denies LMP: 1/14/20- irregular; every 2 moths; or 6 times a year Allergies: YES Medication: Penicillin- rash/hives Food: Denies Environment: Cats and dust- itchy watery eyes, running nose, exacerbates asthma wit sneezing and wheezing. History of Present Illness (HPI) “It feels like it’s been h...