Shadow Health

Documentation / Electronic Health Record Vitals Student Documentation Model Documentation Vitals Initials: T.J. Age: 28 Race: B Gender: F VS: T 37.2 (oral) BP 128/82 (manual) P 78 RR 15 O2 99% (RA) Ht. 5'7" (stated) Wt. 198.41 (standing scale) Spirometer 1.78/1.549 N/A Health History Student Documentation Model Documentation Identifying Data & Reliability Miss Jones is a 28 y/o BF who presents to the clinic for a preemployment physical. She is polite, cooperative, and speech is c...

Introduction An annual physical assessment is important in keeping one healthy. At this visit the patient can establish care with a provider and be evaluated. By having an initial assessment completed the provider has something to compare the individual’s other visits to. This helps the provider to see when changes arise and properly diagnose health issues. Tina Jones is about to begin her new job at an accounting firm. She presents to the clinic for a comprehensive assessment. The purpo...