Do you have any family history of neurological problems Any changes in your bladder (Clarified to Have you had a recent change in your energy level?.) No, I don’t think so. (Clarified to if my energy level has changed.) Have you had any family history of neurological problems (Clarified to Have you had neurological problems?.) […]
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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
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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
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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
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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
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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
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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,
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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
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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
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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
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