Exam (elaborations)
MSN 571 ShadowHealth - Advanced Health and Physical Assessment Across The Lifespan
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ShadowHealth - Advanced Health and Physical Assessment Across The Lifespan
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MSN ShadowHealth - Advanced Health and Physical Assessment Across The Lifespan, 3/31/2021 Comprehensive Assessment (120 min minimum) | Completed | Shadow Health
Comprehensive Assessment (120 min minimum) Results | Turned In
Advanced Physical Assessment Across the Lifespan (FNP) - USU - February 2021, msn572
Return to Assignment (/assignments/470720/)
Your Results Lab Pass (/assignment_attempts/9539340/lab_pass.p
Overview
Documentation / Electronic Health Record
Transcript
Subjective Data Collection Documentation
Objective Data Collection
Vitals
Documentation
Plan My Exam Student Documentation Model Documentation
• Height: 170 cm
Vitals • Weight: 84 kg
• BMI: 29.0
BP 128/82
• Blood Glucose: 100
HR 78
• RR: 15
RR- 15
• HR: 78
Temp 37.2c
• BP:
O2: 99%
• Pulse Ox: 99%
• Temperature: 99.0 F
Health History
Student Documentation Model Documentation
Identifying Data & Reliability Ms. Jones is a pleasant, 28-year-old African American single wo
who presents for a pre-employment physical. She is the primary
Tina Jones, 28yr old AA female, DOB 2/14, came to the clinic with
source of the history. Ms. Jones offers information freely and wit
her mother for a physical for a new job. She appears to be a good
contradiction. Speech is clear and coherent. She maintains eye
historian and answers all questions appropriately.
contact throughout the interview.
General Survey
Patient is well dress, hygeine good with no odor, poster upright,
Ms. Jones is alert and oriented, seated upright on the examinati
mobility is stable, attentive to all questios, attitude good with positive
table, and is in no apparent distress. She is well-nourished, well-
espressions. A&Ox4, very pleasant and cooperative. breathing is at
developed, and dressed appropriately with good hygiene.
ease. VS stable. eye exam 20/20 with snellan chart. HT, weight and
BMI charted. VS taken.
Reason for Visit
“I came in because I'm required to have a recent physical exam
physical for new job the health insurance at my new job.”
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