Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Document: Provider Notes
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, obese 28-year-old African American woman in no acute distress. She is alert and oriented. maintains eye contact throughout interview and examination. Musculoskeletal: Bilateral upper extremities without muscle atrop or joint deformity. Bilateral upper extremities with full range of mo of shoulder, elbow, and wrist. No evidence of swollen joints or sig of infection. Bilateral lower extremities without muscle atrophy or joint deformity, full range of motion of bilateral hips, knees, and ankles. No evidence of swollen joints or signs of infection. Flexio extension, lateral bending, and rotation of the spine with reduced ROM – pain and difficulty. Bilateral upper extremity strength equa and 5/5 in neck, shoulders, elbows, wrists, hands. Bilateral lowe extremity strength equal and 5/5 in hip flexors, knees, and ankles