Nursing

What happens with Penicillin I don’t remember that well because the last time I had penicillin I was pretty little. . . I think I got a rash, like, hives. The doctor told me not to take it again after that. What over the counter medication are you taking Usually I’ll take Tylenol sometimes for […]

What is your medical history I’ve had asthma since I was little, and I have sugar diabetes, too. Are you taking medication for diabetes I don’t take anything for my diabetes anymore. OK, I understand. Are you taking medications for your asthma (Clarified to Do you use medication for your asthma?.) I just use my

Do you have difficulty breathing Do you have difficulty breathing (Clarified to Are you having difficulty breathing right now?.) No, my breathing is fine right now. (Clarified to if I am having difficulty breathing now.) Are you able to concentrate on task Yeah, my concentration seems fine Do you have trouble sleeping Nope. I’ve been

What is the Pain Scale from 1 to 10 (Clarified to Can you rate your current pain level on a scale of 0 to 10?.) It’s just my neck that hurts right now. . . I guess I’d say it’s a 3 out of 10. (Clarified to how I would rate my pain on a

Is there anything that makes it feel better Neurological Results | Turned In Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1 Return to Assignment (/assignments/313478/) Transcript Started: Apr 15, 2020 | Total Time: 126 min Question 04/15/20 6:44 PM MD Question 04/15/20 6:45 PM MD Question 04/15/20 6:45 PM MD Question 04/15/20 6:45 PM MD Question

Student Documentation Model Documentation Objective HENT: WNL No abnormalities found Upper extremiteis: WNL: no abnormality found: ROM: wnl Spine: reduced ROM for extension and flexion and lateral bending Hips: ROM wnl Lower extremity: Root foot with scar: healed well . Strength tests all wnl for upper and lower extremities. General: Ms. Jones is a pleasant,

Subjective Data Collection Objective Data Collection Education & Empathy Documentation Document: Provider Notes   https://aspen.shadowhealth.com/assignments/313477/ https://aspen.shadowhealth.com/assignment_attempts/6633867/lab_pass.pdf   Student Documentation Model Documentation Objective HENT: WNL No abnormalities found Upper extremiteis: WNL: no abnormality found: ROM: wnl Spine: reduced ROM for extension and flexion and lateral bending Hips: ROM wnl Lower extremity: Root foot with scar: healed

Musculoskeletal Results | Turned In Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1 Return to Assignment (/assignments/313477/) Documentation / Electronic Health Record Document: Provider Notes Student Documentation Model Documentation Subjective This is a 28 yo pleasant african american female. She is the primary source of history and offers information freely. she speaks clearly and coherent and

Subjective Documentation in Provider Notes Subjective narrative documentation in Provider Notes is detailed and organized and includes: Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS) ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each

Pulmonary— Lungs are clear to auscultation and percussion bilaterally Diagnostic results: EKG, CXR, CK-MB (support with evidenced and guidelines) A. Differential Diagnosis: 1) Myocardial Infarction (provide supportive documentation with evidence based guidelines). 2) Angina (provide supportive documentation with evidence based guidelines). 3) Costochondritis (provide supportive documentation with evidence based guidelines). Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction