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Transcript:Student Documentation Model Documentation Subjective Data Collection Objective Data Collection Education & Empathy Documentation Document: Vitals Document: Provider Notes   Student Documentation Model Documentation Assessment Differential diagnosis: 1. flu-like syndrome or cold 2. strep throat 3. Allergies 4. Allergic rhinitis My differentials include cold, strep throat, rhinitis, allergies and asthma based on abnormal findings affecting

Your Results Lab Pass Objective Daniel appears slightly tired, and has been coughing throughout the exam Vital signs stable Spirometer: FEV1: 3.15L FVC 3.91L/ 80.5% Head: Cervical lymph nodes enlarged and tender on right side; Sinus: no tenderness on frontal or maxillary eyes: pink in color, no discharge Ears: right ear redness and inflammed: no

Student Documentation Model Documentation Focused Exam: Cough Results | Turned In Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1 Return to Assignment (/assignments/313480/) Documentation / Electronic Health Record Document: Provider Notes Student Documentation Model Documentation Subjective Dany is a 8 year old hispanic boy, brought into clinic by his grandmother. He is able to answer the

Constipation causing abdominal mass Intestinal obstruction Diverticulitis Irritable bowel syndrome Mrs. Park’s bowel sounds are normoactive in all quadrants, with bruits or friction sounds. Scattered dullness in LLQ during percussion is suggestive of feces in the colon; otherwise, her abdomen is tympanic. Her abdomen is soft to palpation; mild guarding and oblong mass suggesting feces

  Document: Vitals Document: Provider Notes Student Documentation Model Documentation Objective Alert and oriented x3: Some discomfort due to abdominal pain HEENT: moist mucus mambrane, normal skin turgor, no tenting Heart: S1 and S2 with no abnormal heart sounds Lungs; CTA Liver: 1cm below Rt costal margin: nontender Abdomen: BS present at all quads, normoactive,

Focused Exam: Abdominal Pain Results | Turned In Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1 Return to Assignment (/assignments/313482/) Documentation / Electronic Health Record Document: Provider Notes Student Documentation Model Documentation Subjective Miss Park is a pleasant Korean 78 year old woman who presents to the clinic with complaints of abdominal pain for the past

Focused Exam: Chest Pain Results | Turned In Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1 Return to Assignment (/assignments/313481/) (/site_notice_dismissals?from_flash=true&site_noticBecome a paid student tester for Shadow Health! Click here for more information (https://www.surveymonkey.com/r/TN9CMB5) (/site_notice_dismissals?from_flash=true&site_noticShadow Health will be performing planned maintenance this Friday, from 7:00am until 7:30am Eastern. During this time assignment attempts will be disabled.

Week 3 Soap Note: Bacterial Vaginosis Running head: Week 3 soap note 1 Week 3 soap note 2 Week 3 Soap Note: Bacterial Vaginosis Bethel U. Godwins Walden University NURS 6551, Section 8, Primary Care of Women June 17, 2016 Week 3 Soap Note: Bacterial Vaginosis Patient Initials: WJ Age: 22 Gender: Female SUBJECTIVE DATA: