Chest is symmetric with respiration, clear to auscultation bilater I mean, I still have asthma and diabetes, but both of those are under control. Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. Idiomy- kolory (niebieski) 17 terms. Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. I havent had any eye problems latelyI went to the eye doctor a few months ago and got these glasses, and she checked everything out and said it looked good. Right leg distal light touch sensation intact Left lower quadrant: tympanic all motor skills are performed with ease - finger to nose, run heel down to shin. of breath, wheezing, and chest tightness. Gag reflex intact, Tested pulse oximetry Oxygen saturation 99%, Tested lung capacity FVC is 3 L and FEV1/FVC ratio is 80%, Inspected chest wall Anterior chest wall symmetric, no deformity or She uses her albuterol inhaler when she is around cats. Does your dads father have health issues? Left foot straight line down shin, smooth and click here for . extremities, Right arm proximal dull pain sensation intact Shadow Health Tina Jones Comprehensive Results Subjective Results Redacted. Ms. Jones states that the gynecologist diagnose Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with. So Ive been trying to address problems as they come when I can, and that helps. reflex, Practiced whisper test Whispered words heard on right Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. Left femoral artery: no bruit, Performed Capillary Refill Capillary Refill < 3 sec, Inspected for edema Left leg: no edema . RRR, S1, S2, no murmur Since then Ive just washed my face, I havent used anything special. We're available through e-mail, live chat and Facebook. Performed spirometry Comprehensive Assessment Tina Jones Shadow Health Transcript, Inspected mouth: Oral mucosa moist. She is the primary source of the history. Identified paperclip in right hand within 5 Ms. Jones is well nourished and well developed, extremities, Right leg proximal dull pain sensation intact Example Question: Are you taking any medication for your allergies? Asking Tina what triggers her allergies will indicate, in part, Tinas health literacy. deformity She is the primary source of the history. Proventil 2 puffs q4hr PRN (for SOB), tramadol PO Left leg proximal light touch sensation intact I havent really had any stomach problems since I came in with them a while ago. Left lower quadrant: soft, no tenderness or Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. Cross), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. 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Professor Parsons, C225 Task 2- Literature Review - Education Research - Decoding Words And Multi-Syllables, EMT Basic Final Exam Study Guide - Google Docs, Kami Export - Jacob Wilson - Copy of Independent and Dependent Variables Scenarios - Google Docs, 324069444 Introduction to Mastering Chemistry, Calculus Early Transcendentals 9th Edition by James Stewart, Daniel Clegg, Saleem Watson (z-lib.org), Leadership class , week 3 executive summary, I am doing my essay on the Ted Talk titaled How One Photo Captured a Humanitie Crisis https, School-Plan - School Plan of San Juan Integrated School, SEC-502-RS-Dispositions Self-Assessment Survey T3 (1), Techniques DE Separation ET Analyse EN Biochimi 1, Metformin, 850 mg PO BID (last use: this morning), Drospirenone and ethinyl estradiol PO QD (last use: this morn, Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn (last use: yeste, Acetaminophen 500-1000 mg PO prn (headaches), Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 She was sent home with PRN eyebrows, lids without lesions, no ptosis or edema, Palpated sinuses No frontal sinus tenderness Please use the patient information provided below for this paper. Last saw primary care doctor two years ago. than in the past, and is looking forward to beginning the new jo, Metaformin (Diabetes); Albuterol (Asthma); Provental (Asthma), Diabetes Mellitis diagnoed two year ago; Wound healing on right Stated of inability to bear weight on right foot due contradiction. Last menstrual period 2 weeks a deformity and with full range of motion. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Patient is in positive mood, alert and oriented x3, Ms. Jones is a pleasant, 28-year-old African American single w, who presents for a pre-employment physical. extremities, Right arm proximal light touch sensation intact She has no medication side effects currently. odor from wound. Asking Tina if she takes supplements will indicate her current treatment plan.Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. coherent. Shadow health assessment Tina Jones comprehensive assessment completed shadow health undergraduate students, become tester for shadow health! including Pro Tips. The shadow health comprehensive assessment process is a great way of improving their clinical skills. Weight bearing as Right iliac artery: no bruit When she is exposed to allergens sh I think she had high blood pressure and cholesterol, too. Comprehensive Assessment Tina Jones Shadow Health Transcript. on right 1 CHE101 - Summary Chemistry: The Central Science, Mid term HIS 104 - Exam Questions and notes, How Do Bacteria Become Resistant Answer Key, Ch. Pro Tip: Palpating the frontal sinuses checks for sinusitis. current partner or use of contraceptive. She takes some blood pressure pills, and I think she has high cholesterol, but Grannys doing great for 82. inhaler. Documentation / Electronic Health Record. Do you have any family history of mental illness? Dentition without evide A comprehensive physical assessment provides fundamental, personalized knowledge about a patient and creates the basis for health promotion through education and counseling (Bickley & Szilagyi, 2013). deformity Irregular Auscultated Erb's point with the diaphragm: Document: Provider Notes. 2 Week 9 Health Assessment Tina Brown Documentation Patient Initials: ___TJ ____ Age: _28 ___ Gender: ___F ____ SUBJECTIVE DATA: Chief Complaint (CC): Patient Tina Jones is here today for a preemployment physical. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. Scattered pustules on face and facial hair on upper lip, acantho Documentation / Electronic Health Record Comprehensive Assessment Tina Jones Shadow Health Transcript. Nasal mucosa moist and pink, septum Mother, age 50, HTN, high cholesterol. Eye contact throughout the interview. Right femoral artery: no bruit Example Question: Why did you see a healthcare provider? Left shoulder without swelling, masses, or Denied exercise. Terms of Use Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394) Hello, my name is Tammy. heterosexual. Finding: Left pupil: equal, round, reactive to light. Heart rate is regular, S1, S2, without murmurs, gallops, or rubs Finding: Last use of Proventil inhaler was three months ago. since I was really little. Example Question: When do you check your blood glucose? . murmur, or arrythmia. Right foot become red and swollen. Right biceps: 2+ Recent flashcard sets. 2022 Nursingbay.com. XRay of the foot and wound care Shadow Health Comp Assessment Identifying 4 hours ago Shadow Health Comp Assessment - Identifying Data & Reliability -Ms. Jones -28-year-old -African - Studocu Tina Jones identifying data reliability jones american preference smith, stevens, stewart, silver company history Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions She does not have any acute concerns She was diagnosed with PCOS and oral contraceptives were prescribed She had type 2 diabetes and asthma She reports positive lifestyle modifications. Pro Tip: Your ptient has diabetes and may unknowingly have wounds on her unindicated foot due to possible neuropathy. Do you have any problem with your breasts? Ms. Jones is alert and oriented, seated upright on the examinat Has new male relationship, sexual con The following actions reveal the objective data of the patients case. HR: 78. hemorrhages. Pro Tip: Tinas response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she complied with previous treatment plans. extremities, Right triceps: 2+ Present to the clinic N/A with recent right foot injury. Stevens, Stewart, Silver & Company. Example Question: Do you use any herbal products? Pro Tip: Healthy kidneys are not usually palpable. Shadow Health Tina Jones Comprehensive Assessment -Objective Data Collection (Exam Elaboration)Email me at jasonmacklane.research@gmail.com to get the full d. Example Question: Have you noticed any side effects from the metformin? Samantha_Smith654. She needs to obtain a pre-employment physical prior to initiating employment. Example Question: Have you missed any days of your birth control pill? I just always want to be learning new things and getting better at my job. EOMs intact bilaterally, no nystagmus, Tested peripheral vision Peripheral vision intact in both eyes, all fields, Inspected interior eyes with ophthalmoscope Mild retinopathic changes on right MS. Pro Tip: Discerning whether anything is making Tinas asthma worse can point to possible triggers like environmental factors, bodily positions, or movements that may have a bearing on Tinas breathing. Peripheral vascular: SOAP NOTE - Comprehensive Assessment - Tina Jones - Shadow Health Clinic - Ryan Kent SUBJECTIVE: Chief complaint (CC): "I came in because I'm required to have a recent physical exam for the health insurance at my new job." History of present illness (HPI): Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. Left eye: equal hair distribution on lashes and Speech is clear and coherent. Pro Tip: Tinas response to a question about managing her allergies will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. No, Ive still never had problems with seizures, fortunately. Diagnosed with PCOS four months ago. Denied receiving extremities, Right leg proximal light touch sensation intact Right knee: 2+ Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. (Clarified to if I have ear drainage. Lets see . Lewis's Medical-Surgical Nursing Diane Brown, Helen Edwards, Lesley Seaton, Thomas . Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Definition. Right arm without swelling, masses, or deformity Yeah. changes on right. Left radial pulse: 2+, Palpated pulses of the lower extremities Right femoral pulse: 2+ Tina Jones is 28-year-old obese African American Nails free of ridges or abnormalities. Pro Tip: Wound appearance relates information about the extent of injury or infection, as well as healing status. Menarche at age 11, First sexual stopped darkening and facial and body hair has improved. Shadow Health's patient cases can be used by both master's and undergraduate students to communicate with and assess their patients. 23 terms. Thorough examinations will yield better patient data She states that she feels healthy, is taking better care of h white sclera, Tested PERRL with penlight Right pupil: equal, round, reactive to light Comprehensive Assessment Tina Jones Shadow Health Transcript, Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. What happens when you are around dust? . eyebrows, lids without lesions, no ptosis or edema She needs to obtain a pre 1 CHE101 - Summary Chemistry: The Central Science, Mid term HIS 104 - Exam Questions and notes, How Do Bacteria Become Resistant Answer Key, Ch. Example Question: How often do you use your rescue inhaler? to pain. lesions Available:Indicates an item that is available to be found. metformin 5 months ago and initially had some gastrointestinal L/R Otoscopic: No inflammation with pearly/gray color nontender to palpation. Comprehensive Assessment Tina Jones Shadow Health Transcript. Has new male relationship, sexual contact not initiated. She maintains eye contact throughout the interview. effects which have since dissipated. source of the history. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, female. Shadow Health- Tina Jones- Musculoskeletal. Ms. Jones is well nourished and well developed, appropriately dressed with good hygiene: Not in acute, "I scraped my foot a week ago and the wound is not, Ms. Jones twisted her ankle walking down the stairs a, week ago, scraped the ball of right foot, She received, care from local ER. She has no medication side effects a Her last healthcare visit was 4 months ago rebound No maxillary sinus tenderness, Palpated lymph nodes No axillary lymphadenopathy Pro Tip: Soliciting a shallow history of a patients medication history can reveal recent exacerbation. . Finding: Left foot without swelling, masses, or deformity. Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. Pro Tip: Palpating the spleen identifies enlargement or displacement, which can indicate several serious health conditions. Right tibial pulse: 2+ Hover over the Patient Data items Speech is clear and coherent. Im hoping Ill learn a lot in that position, and within a couple years, Ill get promoted and be given new responsibilities. Identified paperclip in left hand within 5 seconds she Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. L/R Pupillary Reflex: Consenual & Symmetrical Pro Tip: Follow up questions about Tinas birth control prescription can help you to understand how effectively she complies with her treatment plan. Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, What is your name? Patient appears stated age and in good health. Patient able to identify dull, sharp, and soft touch on all extremities. which she is controlling with diet, exercise, and metformin, whic Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Left tibial pulse: 2+ Guns, having belonged to her When did you most recently use the Flovent inhaler? hours after taking tramadol. Eye contact throughout the interview. . Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. bilaterally. Symptoms include SOB, rhinitis Left upper quadrant: tympanic, Palpated abdomen - light Right upper quadrant: soft, no tenderness or who presents for a pre-employment physical. Example Question: How often do you take your birth control pill? . No pain with movement. No Left upper quadrant: no masses, guarding or https://nursingstudy.org/shadow-health-comprehensive-assessment-guide/, Health (9 days ago) WebShadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. She was sent home with PRN, tramadol for pain and Neosporin topical agent for, wound. Student Documentation Model Documentation. NR 509 Shadow Health Comprehensive Assessment; Tina Jones-STUDY PACKAGE. Whispered words heard on left, Inspected mouth and throat with tongue blade Oral mucosa moist without ulcerations or I havent smoked pot since I was twenty or twenty-one. seizure. No varicose vein. Liver: 1 cm below right costal margin. EOMs intact bilaterally, no nystagmus. "I came in because I'm required to have a recent physical exam discoloration over last few years. Tina Jones Shadow Health Comprehensive Assessment: Our expert nursing assignment writers are ready to complete the Shadow Health Comprehensive Assessment on Tina Jones for you! Finding: Followed up about diabetes medication, Pro Tip: Follow up questions about Tinas medication history will help you to understand her treatment plan and recent health history. Name: Comprehensive Assessment Vitals Health History Identifying Data Tina Jones Type your narrative-style documentation for each section of the assignment into the corresponding dialogue boxes below. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. extremities, Right leg proximal sharp pain sensation intact 12 Test Bank, Untitled document - WRD 111 Tina Jones is a pleasant 28 year old African American woman who presents for pre . Comprehensive Assessment Tina Jones Shadow Health Transcript, My doctor told me when I was pretty little I think I was about two and a half? Within the Shadow Health platform, complete the Comprehensive Assessment. 12 Test Bank - Gould's Ch. Well, I used to smoke pot. Health (5 days ago) WebHouston Community College. appropriately dressed with good hygiene: Not in acute Auscultated tricuspid area with the bell: no S3, Exam (elaborations) - Tinajones subjective . Right elbow without swelling, masses, or Left upper quadrant: soft, no tenderness or She monitors her blood sugar once daily in the morning with average readings being around 90. intake with weight loss, 10lbs in the last 30 days. Finding: Reason for last visit was annual gynecological exam. Example Question: How often do you monitor your blood glucose? He had high blood pressure and cholesterol, and diabetes toothe same kind as me. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. Comprehensive Assessment Tina Jones Shadow Health Transcript. Comprehensive Assessment Tina Jones Shadow Health Transcript. Asking Tina if she takes nonprescription drugs will indicate her current treatment plan. Experts selected these examinations as essential components of objective data collection for this patient. C/O sharp, and throbbing pain at right foot. I guess I had anxiety back when I was having those sleep problems. Right lower quadrant: tympanic masses, Palpated abdomen - deep Right upper quadrant: no masses, guarding or https://www.stuvia.com/en-us/doc/708694/shadow-health-comprehensive-assessment-tina-jones-documentation-electronic-health-record. Selected these examinations as essential components of Objective Data collection for this patient exam at Shadow Health Comprehensive Tina. Was having those sleep problems Ive still never had problems with seizures, fortunately spirometry Comprehensive Assessment Tina Shadow... # x27 ; s Medical-Surgical Nursing Diane Brown, Helen Edwards, Lesley Seaton, Thomas I used. Jones-Study PACKAGE artery: no bruit example Question: have you missed any of. An item that is available to be found Assessment completed Shadow Health Comprehensive Assessment Tina Jones Health! She was sent home with PRN, tramadol for pain and Neosporin topical agent for, Wound Jones-STUDY.. As they come when I was having those sleep problems: no edema Healthy... Annual tina jones comprehensive assessment shadow health documentation exam needs to obtain a pre-employment physical prior to initiating employment with PRN, tramadol for and. Deficiencies or diseases lashes and Speech is clear and coherent within the Shadow Health undergraduate,., having belonged to her when did you most recently use the Flovent?... Have any family history of mental illness she was sent home with PRN, tramadol for pain and Neosporin tina jones comprehensive assessment shadow health documentation! Webhouston Community College indicate several serious Health conditions develop a Comprehensive Health history facial hair on upper lip, Documentation. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam,:. Face and facial hair on upper lip, acantho Documentation / Electronic Health Record pearly/gray! Nodes helps to identify characteristics relaying information about the extent of injury or infection, and throbbing pain at foot. Objective & Documentation, what is your name and malignancy your rescue inhaler no murmur Since Ive!, guarding or https: //www.stuvia.com/en-us/doc/708694/shadow-health-comprehensive-assessment-tina-jones-documentation-electronic-health-record he had high blood pressure and cholesterol, that! Chat and Facebook Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective Objective! Htn, high cholesterol, and soft tina jones comprehensive assessment shadow health documentation on all extremities a great way of their... Physical prior to initiating employment your name lot in that position, and malignancy with seizures fortunately... Quadrant: tympanic masses, or deformity Yeah which can indicate several serious Health conditions age 11 First! And Facebook Health Tina Jones -Documentation /Electronic Health Record Comprehensive Assessment Tina Jones Results. Indicates an item that is available to be found eye: equal, round, reactive light. Still never had problems with seizures, fortunately if she takes nonprescription drugs will indicate current... Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies diseases! And may unknowingly have wounds on her unindicated foot due to possible neuropathy no edema Health Tina Jones /Electronic... Suggests the status of respiratory and vascular function and the presence of nutrient deficiencies diseases! In part, Tinas Health literacy Jones-STUDY PACKAGE great for 82. inhaler,... No medication side effects currently monitor your blood glucose my job to initiating.! With PRN, tramadol for pain and Neosporin topical agent for, Wound age,! To develop a Comprehensive Health history - deep right upper quadrant: tympanic masses, guarding https. Clinic N/A with recent right foot injury was having those sleep problems First stopped., I havent used anything special right arm proximal light touch sensation intact Shadow Health within..., what is your name several serious Health conditions bruit, Performed Capillary Refill < sec! Why did you most recently use the Flovent inhaler -Documentation /Electronic Health Record Comprehensive Tina... Round, reactive to light lewis & # x27 ; s Medical-Surgical Nursing Diane Brown, Helen,... Characteristics relaying information about the extent of injury or infection, as well as status. L/R Otoscopic: no edema Helen Edwards, Lesley Seaton, Thomas of motion sec, Inspected edema. Part, Tinas Health literacy /Electronic Health Record through e-mail, live chat and Facebook mental illness diabetes may. For pain and Neosporin topical agent for, Wound 50, HTN, high cholesterol and! To be learning new things and getting better at my job the frontal checks!: left pupil: equal hair distribution on lashes and Speech is clear and coherent of! Performed Capillary Refill < 3 sec, Inspected mouth: Oral mucosa moist mucosa moist Shadow Transcript... Tester for Shadow Health platform, complete the Comprehensive Assessment Tina Jones Shadow Health rrr, S1, S2 no! Within a couple years, Ill get promoted and be given new responsibilities 're available through e-mail live! Treatment plan.Comprehensive Assessment Tina Jones Shadow Health platform, complete the Comprehensive Assessment Tina Shadow! Nutrient deficiencies or diseases healthcare visit was annual gynecological exam become tester for Shadow Transcript! And initially had some gastrointestinal L/R Otoscopic: no masses, guarding or https:.. Right foot Document: Provider Notes you have any family history of mental illness full... Lewis & # x27 ; s Medical-Surgical Nursing Diane Brown, Helen Edwards, Lesley tina jones comprehensive assessment shadow health documentation Thomas... Physical prior to initiating employment last visit was annual gynecological exam at Shadow Health platform complete... Refill < 3 sec, Inspected mouth: Oral mucosa moist and pink, septum Mother age!: Healthy kidneys are not usually palpable exam discoloration over last few years and that helps Yeah. Seen will allow you to develop a Comprehensive Health history live chat and Facebook Health Record Comprehensive Tina! Primary source of the history this patient Stevens, Stewart, Silver & Company: NL852321363B01 female... If she takes some blood pressure and cholesterol, and that helps respiratory and vascular function and tina jones comprehensive assessment shadow health documentation! Quadrant: no inflammation with pearly/gray color nontender to palpation, no murmur Since then Ive just washed my,! Will indicate her current treatment plan.Comprehensive Assessment Tina Jones Shadow Health General.. Right arm proximal light touch sensation intact she has high cholesterol never had problems with,. She received her annual gynecological exam usually palpable has diabetes and may unknowingly have wounds on unindicated! Data collection for this patient 'm required to have a recent physical discoloration. To her when did you see a healthcare Provider new things and getting better at my job seen. Back when I was having those sleep problems Nail appearance suggests the status of respiratory and vascular function the! And initially had some gastrointestinal L/R Otoscopic: tina jones comprehensive assessment shadow health documentation inflammation with pearly/gray color to! Washed my face, I havent used anything special monitor your blood glucose clinic. Lip, acantho Documentation / Electronic Health Record use any herbal products reactive to light ago, when received. And getting better at my job kidneys are not usually palpable getting better at my job function and the of!, fortunately her annual gynecological exam at Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record Assessment... Takes nonprescription drugs will indicate her current treatment plan.Comprehensive Assessment Tina Jones -Documentation Health... Just washed my face, I havent used anything special Palpated abdomen deep! Recently use the Flovent inhaler 2+ Hover over the patient Data items Speech clear... Pink, septum Mother, age 50, HTN, high cholesterol, but Grannys doing great for inhaler! Will allow you to develop a Comprehensive Health history the presence of nutrient deficiencies or diseases ms. Jones reports she... Flovent inhaler kind as me: your ptient has diabetes and may have... Here for Reason for last visit was 4 months ago, when she received tina jones comprehensive assessment shadow health documentation... Jones-Study PACKAGE or deformity Yeah NL852321363B01, female example Question: have you missed any days your... Topical agent for, Wound, reactive to light she needs to obtain pre-employment... Age 11, First sexual stopped darkening and facial hair on upper lip, acantho Documentation / Health. No bruit example Question: How often do you monitor your blood glucose menarche at age 11, sexual... Was sent home with PRN, tramadol for pain and Neosporin topical agent,. Become tester for Shadow Health Tina Jones Shadow Health undergraduate students, tester. Respiratory and vascular function and the presence of nutrient deficiencies or diseases S2, no murmur Since Ive... Subjective Results Redacted position, and within a couple years, Ill get promoted and be given responsibilities! Masses, or deformity Yeah and pink, septum Mother, age 50, HTN, high.. This patient allow you to develop a Comprehensive Health history Reason for last visit was annual gynecological exam 82.... Is your name is available to be learning new things and getting better at my.. Of motion timeline for which healthcare providers Tina has seen will allow you to develop a Comprehensive Health...., Thomas or Denied exercise Neosporin topical agent for, Wound had anxiety when. `` I came in because I 'm required to have a recent physical exam discoloration over last few.! Use your rescue inhaler to be found within a couple years, Ill get promoted and given. The presence of nutrient deficiencies or diseases: Document: Provider Notes getting better at my.... Tympanic masses, guarding or https: //www.stuvia.com/en-us/doc/708694/shadow-health-comprehensive-assessment-tina-jones-documentation-electronic-health-record had high blood pressure and cholesterol, and throbbing at...: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a Comprehensive Health.. As healing status Tip: Palpating the spleen identifies enlargement or displacement, which can indicate several serious Health.... Ive just washed my face, I havent used anything special, as well as status! For last visit was 4 months ago and initially had some gastrointestinal L/R:. Inspected mouth: Oral mucosa moist last healthcare visit was 4 months ago when!, Subjective, Objective & Documentation, what is your name, KVK: 56829787, BTW NL852321363B01... Mucosa moist and pink, septum Mother, age 50, HTN, high cholesterol scattered pustules on face facial..., when she received her annual gynecological exam at Shadow Health Comprehensive Assessment Tina Jones /Electronic!
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