Shadow Health Tina Jones Documentation. Electronic Health Record-Completed 2021

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Health History Results | Completed Return to Assignment (/assignments/140509/) Documentation / Electronic Health Record Document: Provider Notes Student Documentation Model Documentation Identi... fying Data & Reliability Ms. Tina Jones 28 year old , African American, single who presents to the clinic with concerns of her recent right foot injury. Ms. Jones is pleasant and good historian. Ms. Jones is a pleasant, 28-year-old obese African American s woman who presents to establish care and with a recent right f injury. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear an coherent. She maintains eye contact throughout the interview. General Survey Ms. Jones is alert and oriented, no apparent distress, properly groomed. Ms. Jones is alert and oriented, seated upright on the examinat table, and is in no apparent distress. She is well-nourished, we developed, and dressed appropriately with good hygiene. Chief Complaint Patient reports that she sustained a scraped at the plantar surface of her foot. The wound is draining with pus, no fouly smell but the pain is bothering her, and the pain got worse of the last 2 days. Patient states that the "pain is killing me". “I got this scrape on my foot a while ago, and I thought it would up on its own, but now it's looking pretty nasty. And the pain is killing me!” History Of Present Illness Patient states that she was doing down the back steps. She tripped, and caught the railing, and kind of turned her ankle. She scraped up her foot on the edge of the step. She went to the ER with concerns that she fracture her ankle. While in ER they xray the ankle and the foot , the result shows negative for fracture. She was sent with prescription of tramadol. Patient is taking the pain medications three times a day. Patient states the pain is relieved by medication but only for a few hours, and then she starts feeling the throbbing pain. Patient states that she clean the wound with soap and water and put neosporin and wrap it with bandage twice a day. Ms. Jones states that the wound get worst. The discharge in the wound is oozing, but clear drainage, and the wound feels warm and get more swollen. She reported to having a fever with a temperature of 102 last night. Reported that about a month ago she lose weight 10lbs without trying. No changes of diet and level of activity. Ms. Jones reports that a week ago she tripped while walking on concrete stairs outside, twisting her right ankle and scraping the of her foot. She sought care in a local emergency department where she had x-rays that were negative; she was treated with tramadol for pain. She has been cleansing the site twice a day. has been applying antibiotic ointment and a bandage. She repo that ankle swelling and pain have resolved but that the bottom the foot is increasingly painful. The pain is described as “throbb and “sharp” with weight bearing. She states her ankle “ached” b resolved. Pain is rated 7 out of 10 after a recent dose of tramad Pain is rated 9 with weight bearing. She reports that over the pa two days the ball of the foot has become swollen and increasin red; yesterday she noted discharge oozing from the wound. Sh denies any odor from the wound. Her shoes feel tight. She has been wearing slip-ons. She reports fever of 102 last night. She denies recent illness. Reports a 10-pound, unintentional weight over the month and increased appetite. Denies change in diet o level of activit [Show More]

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