Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record.

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Health History Student Documentation Model Documentation Identifying Data & Reliability The patient does not give reliable report of health history as her mediation, symptoms and hospitalization r... eport was different each time I asked. She seemed to hesitate and have confusion with dates. She has no primary health care provider. She leaves out information about meds and diagnosis that are only uncovered by rephrasing question. Ms. Jones is a pleasant, 28-year-old African American single wo who presents for a pre-employment physical. She is the primary source of the history. Ms. Jones offers information freely and wit contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview. General Survey The patient is healthy and able to work. She reports being happy with past history of some stress and insomnia which have resolved. . Rx Yaz improved symptoms; last period 6 wks ago. Takes Yaz 1x daily. Allergies to penicillin (hives), cats, dust (sneeze) and asthma acts up - asthma dx at 2 years old. Reports loss of breath going up stairs. Rx albuterol 2-3 daily. Last took yesterday when she wheezed going up stairs. Reports fatigue/ feeling full after eating sugar, glucose 90. Rx metformin causes gas, 2x daily (850 mg). Overall healthy hospitalizations asthma. Ms. Jones is alert and oriented, seated upright on the examinatio table, and is in no apparent distress. She is well-nourished, welldeveloped, and dressed appropriately with good hygiene. [Show More]

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