NR 509 Tina Jones Comprehensive Health Assessment<\/p>\n
Documentation \/ Digital Health Document<\/p>\n
Documentation
\nVitals<\/p>\n
Scholar Documentation\tMannequin Documentation
\nBP 128\/82 P 78 RR 15 Temp 37.2 O2 99% Weight 84kg Top 5\u20196\u2033 BMI 29 BS 100\t\u2022 Top: 170 cm \u2022 Weight: 84 kg \u2022 BMI: 29.zero \u2022 Blood Glucose: 100 \u2022 RR: 15 \u2022 HR: 78 \u2022 BP:128 \/ 82 \u2022 Pulse Ox: 99% \u2022 Temperature: 99.zero F
\nHealth Historical past<\/p>\n
Scholar Documentation\tMannequin Documentation
\nFiguring out Knowledge & Reliability
\nMs. Jones is a pleasing 28 yr previous African American feminine who presents to the clinic at this time for a bodily for employment. Pt\u2019s responses are applicable, maintains eye contact all through examination.<\/p>\n
Ms. Jones is a pleasing, 28-year-old African American single girl who presents for a pre-employment bodily. She is the first supply of the historical past. Ms. Jones provides data freely and with out contradiction. Speech is evident and coherent. She maintains eye contact all through the interview.
\nCommon Survey
\nPt in no obvious misery, alert and oriented x four, calm and cooperative, appropriately dressed wtih good hygiene.<\/p>\n
Ms. Jones is alert and oriented, seated upright on the examination desk, and is in no obvious misery. She is well-nourished, well-developed, and dressed appropriately with good hygiene.
\nCause for Go to
\nPt states she wants an employment bodily for a brand new job she will likely be starting in two weeks.<\/p>\n
\u201cI got here in as a result of I\u2019m required to have a latest bodily examination for the medical health insurance at my new job.\u201d
\nHistorical past of Current Sickness
\nPt presents to the clininc for an employment bodily that she’s going to start in two weeks. Pt denies any medical points or issues. \u2026 CONT<\/p>\n
Ms. Jones experiences that she just lately obtained employment at Smith, Stevens, Stewart, Silver & Firm. \u2026. CONT
\nDrugs
\nFlovent 110mcg 2 puffs BID Albuterol 90mcg 2 puffs PRN Metformin 850mg PO BID Advil OTC common power PRN for cramps Yaz PO QD contraception<\/p>\n
\u2022 Fluticasone propionate, 110 mcg 2 puffs BID (final use: this morning) \u2026 CONT
\nAllergic reactions
\nPCN- pores and skin rash Cats- exacerbates bronchial asthma Mud-exacerbates bronchial asthma, itchy<\/p>\n
\u2022 Penicillin: rash \u2022 CONT
\nMedical Historical past
\nBronchial asthma- \u2026 CONT<\/p>\n
Bronchial asthma recognized at age 2 1\/2. \u2026 CONT
\nHealth Upkeep
\nSince final encounter \u2026 CONT<\/p>\n
Final Pap smear four months in the past. Final eye examination three months in the past. Final dental examination 5 months in the past. \u2026 CONT
\nHousehold Historical past
\nMom 50- excessive ldl cholesterol and HTN Father- deceased at 58, excessive ldl cholesterol, diabetes, and HTN Maternal grandmother- deeased at 73 from stroke, had HTN and excessive ldl cholesterol Maternal grandfather- deceased at 80 from coronary heart assault, had HTN and ldl cholesterol Paternal grandmother 82- excessive ldl cholesterol, HTN Paternal grandfather- deceased from colon most cancers mid sixties, had excessive ldl cholesterol, diabetes, and HTN Sister 15- Bronchial asthma Brother 26- overweight Paternal uncle- alcholism Denies some other household medical historical past.<\/p>\n
\u2022 Mom: age 50, hypertension, elevated ldl cholesterol \u2022 Father: deceased in automotive accident one yr in the past at age 58, hypertension, excessive ldl cholesterol, and sort 2 diabetes \u2022 Brother (Michael, 25): chubby \u2022 Sister (Britney, 14): bronchial asthma \u2022 Maternal grandmother: died at age 73 of a stroke, historical past of hypertension, excessive ldl cholesterol \u2022 Maternal grandfather: died at age 78 of a stroke, historical past of hypertension, excessive ldl cholesterol \u2022 Paternal grandmother: nonetheless dwelling, age 82, hypertension \u2022 Paternal grandfather: died at age 65 of colon most cancers, historical past of sort 2 diabetes \u2022 Paternal uncle: alcoholism \u2022 Unfavorable for psychological sickness, different cancers, sudden dying, kidney illness, sickle cell anemia, thyroid issues
\nSocial Historical past
\nPt simply graduated faculty with an accounting diploma, by no means married, no kids, pt in a relationship with a male, pt denies smoking or drug use, occasional alcohol with associates. Pt likes to learn, presently lives at residence along with her mom and sister however has plans to maneuver out subsequent month.<\/p>\n
By no means married, no kids. \u2026 CONT
\nPsychological Health Historical past
\nPt denies any \u2026 CONT<\/p>\n
Experiences decreased stress and improved coping skills \u2026. CONT
\nAssessment of Techniques \u2013 Common
\nCommon: no weak point, fatigue or fevers. Constructive weight lack of 10 kilos. Pores and skin: no rashes, lesions, dry pores and skin, ithcing or clor modifications, no dandruff, or modifications in nails. HEENT: \u2026 CONT<\/p>\n
No latest or frequent sickness, \u2026 CONT
\nCLICK HERE TO ORDER NR 509 Tina Jones Comprehensive Health Assessment
\nHEENT
\nScholar Documentation\tMannequin Documentation
\nSubjective
\nDenies complications, eye ache or points, no sinus strain, ,,, CONT<\/p>\n
Experiences no present headache and no historical past of head damage or acute visible modifications. \u2026 CONT
\nGoal
\nNo apparent accidents or bruising. Head is normocephalic. ,,, CONT<\/p>\n
Head is normocephalic, atraumatic. Bilateral eyes with equal hair distribution on lashes and eyebrows, \u2026 CONT
\nNR 509 Tina Jones Comprehensive Health Assessment<\/p>\n
Respiratory
\nScholar Documentation\tMannequin Documentation
\nSubjective
\nPt denies shortness of breath, tough respiration, wheezing or cough. Pt has historical past of bronchial asthma. Denies sinus strain or rhinnorhea.<\/p>\n
Experiences no shortness of breath, wheezing, chest ache, dyspnea, or cough.
\nGoal
\nPeak movement x3: \u2026 CONT<\/p>\n
Chest is symmetric \u2026 CONT
\nNR 509 Tina Jones Comprehensive Health Assessment<\/p>\n
Cardiovascular<\/p>\n
Scholar Documentation\tMannequin Documentation
\nSubjective
\nPt denies chest ache, palpitaitons, or edema. No historical past of anemia or simple bruising.<\/p>\n
Experiences no palpitations, tachycardia, simple bruising, or edema.
\nGoal
\nS1, S2 heard with regular charge and rythm, no murmurs or gallops famous on auscultation. \u2026 CONT<\/p>\n
Coronary heart charge is common, S1, S2, with out murmurs, gallops, or rubs. \u2026 CONT
\nNR 509 Tina Jones Comprehensive Health Assessment<\/p>\n
Belly<\/p>\n
Scholar Documentation\tMannequin Documentation
\nSubjective
\nPt denies any nausea, vomiting, diarrhea, constipation, belly ache or discomfort. \u2026 CONT<\/p>\n
Gastrointestinal: \u2026 CONT.
\nGoal
\nStomach no seen brusing or lesions, protuberant,\u2026 CONT<\/p>\n
Stomach protuberant,\u2026 CONT
\nMusculoskeletal<\/p>\n
Scholar Documentation\tMannequin Documentation
\nSubjective
\nPt denies no joint or muscle ache, no weak point or edema.<\/p>\n
Experiences no muscle ache, joint ache, muscle weak point, or swelling.
\nGoal
\nNo apparent accidents \u2026 CONT<\/p>\n
Power 5\/5\u2026 CONT
\nNR 509 Tina Jones Comprehensive Health Assessment<\/p>\n
Neurological
\nScholar Documentation\tMannequin Documentation
\nSubjective
\nPt denies any numbness or tingling sensations, \u2026 CONT<\/p>\n
Experiences no dizziness, \u2026 CONT
\nGoal
\nGraphesthesia, stereognosis intact. Pt alert and oriented x four. \u2026 CONT<\/p>\n
Regular graphesthesia, \u2026 CONT
\nPores and skin, Hair & Nails<\/p>\n
Scholar Documentation\tMannequin Documentation
\nSubjective
\nPt denies rashes, \u2026 CONT<\/p>\n
Experiences improved pimples attributable to \u2026 CONT
\nGoal
\nNo apparent accidents, lacerations, rashes, dandruff, or bruising. Pt\u2019s hair effectively groomed with even hair distribution. No nail deformities famous in all extremities, clear with no ridges. Extreme hair progress on umbilicus, skinny hair progress on higher lip.<\/p>\n
Scattered pustules on face and facial hair on higher lip, acanthosis nigricans on posterior neck. Nails fre
\nNR 509 Tina Jones Comprehensive Health Assessment RUBRIC
\nRubric<\/p>\n
Can\u2019t change a rubric when you\u2019ve began utilizing it.<\/p>\n
Discover a Rubric<\/p>\n
Title: Discover Rubric<\/p>\n
Shadow Health Bodily Assessment Rubric<\/p>\n
You\u2019ve already rated college students with this rubric. Any main modifications might have an effect on their Assessment outcomes.<\/p>\n
Shadow Health Bodily Assessment Rubric
\nStandards\tScores\tPts
\nEdit criterion descriptionDelete criterion row
\nThis criterion is linked to a Studying OutcomeSubjective Knowledge, Group, Communication, and Abstract (DCE Rating or transcript) _9172<\/p>\n
view longer description<\/p>\n
Vary<\/p>\n
threshold: pts<\/p>\n
Edit ratingDelete ranking
\n25.zero to >21.zero pts<\/p>\n
Above Common- DCE Rating higher than or equal to 93; Comprehensive introduction with expectations of examination verbalized; questions worded in a non-judgmental approach; skilled language exercised; questions well-organized; applicable closing with abstract of findings verbalized to affected person.<\/p>\n
_7235<\/p>\n
Edit ratingDelete ranking
\n21.zero to >10.zero pts<\/p>\n
Common- DCE Rating higher than or equal to 86-92; Ample introduction; some questions worded in a non-judgmental approach; skilled language principally exercised; questions usually organized; considerably full closing.<\/p>\n
_9258<\/p>\n
Edit ratingDelete ranking
\n10.zero to >zero.zero pts<\/p>\n
Beneath Common- DCE Rating higher than or equal to 80-85; Incomplete introduction; many questions worded in a judgmental approach; some skilled language exercised; questions considerably organized; incomplete closing.<\/p>\n
_2206<\/p>\n
Edit ratingDelete ranking
\nzero.zero to >zero pts<\/p>\n
Unsatisfactory- DCE Rating lower than or equal to 79; Introduction lacking; questions worded in a judgmental approach; little skilled language; questions unorganized; closing lacking.<\/p>\n
_4625<\/p>\n
This space will likely be utilized by the assessor to depart feedback associated to this criterion.<\/p>\n
pts
\n\/ 25.zero pts<\/p>\n
\u2014<\/p>\n
Edit criterion descriptionDelete criterion row
\nThis criterion is linked to a Studying OutcomeObjective Knowledge, Bodily Examination, Interpretation of Findings, Assessment, and Documentation _5446<\/p>\n
view longer description<\/p>\n
Vary<\/p>\n
threshold: pts<\/p>\n
Edit ratingDelete ranking
\n20.zero to >16.zero pts<\/p>\n
Above Common- Bodily Assessment documentation consists of all related physique techniques; all pertinent regular and irregular findings recognized; documentation displays skilled language; remedy plan consists of every of the next elements: diagnostics, medicine, schooling, session\/referral, and follow-up planning.<\/p>\n
_8504<\/p>\n
Edit ratingDelete ranking
\n16.zero to >eight.zero pts<\/p>\n
Common- Bodily Assessment documentation lacks ample particulars pertaining to 1 or two related physique techniques; or identifies \u2265 50% of the pertinent regular and irregular findings; or documentation lacks skilled language; or remedy plan lacks one or two elements (diagnostics, medicine, schooling, session\/referral, or follow-up planning).<\/p>\n
_9311<\/p>\n
Edit ratingDelete ranking
\neight.zero to >zero.zero pts<\/p>\n
Beneath Common- Bodily Assessment documentation lacks ample particulars pertaining to 3 or extra related physique techniques; or identifies < 49% of the pertinent regular and irregular findings; or documentation consists of unprofessional language; or remedy plan lacks three or extra elements (diagnostics, medicine, schooling, session\/referral, or follow-up planning).<\/p>\n
_1424<\/p>\n
Edit ratingDelete ranking
\nzero.zero to >zero pts<\/p>\n
Unsatisfactory- No bodily Assessment documentation or no remedy<\/p>\n","protected":false},"excerpt":{"rendered":"
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