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...
VERIFIED 2024 NUR 4500 A ALL MED SURGE EXAMS QUESTIONS & CORRECT ANSWERS100%
APPROVED 2025 HESI MENTAL HEALTH QUESTIONS AND DETAILED ANSWERSWITH RATIONALES GRADED A+
DETAILED NCLEX RN QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES GRADEDA+
APPROVED 2025 ATI PN Comprehensive Predictor Questions and 100% Verified Answers
VERIFIED May 2024 Pearson Edexcel Level 3 GCE A level English LiteratureAdvanced PAPER 1: Drama MERGED QUESTION PAPER> MARK SCHEME> 100% GUARANTEE