NUR 3067C - Health Assessment HEENT Documentation Shadow Health Tina Jones.-North West Florida State University

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Documentation / Electronic Health Record Document: Provider Notes Objective Data Collection Education & Empathy Documentation Document: Provider Notes Student Documentation Model Doc... umentation Lifespan Review Questions Self-Reflection Subjective HPI. Ms Tina Jones is a 28 yo African Woman. She presented to the clinic with complaints of sore and itchy throat, runny nose, and itchy eyes. These symptoms started about a week ago. According to her the symptoms began all of the sudden, and since then it persists and constant. She takes throat drops and plenty of water to help relief the pain of her sore throat. She denies of taking any other medications to help with her sore throat. The sore on her throat is a little worst in the morning and the pain is constant. She describe the pain as mild to moderate. She states that her nose has a clear watery drainage, and it "runs all day", and the drainage is thin and drippy. She denies of pain, sneezing and clog nose. She does not take any medication to relieve the symptoms of her nose. She also has an itchy eyes . She denies of any recent illness. She report of no fever, chills or night sweat. Denies of being diagnosed with seasonal allergy, but states [Show More]

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