NR 509 Shadow Health Documentation / Electronic Health Record 2017
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Documentation / Electronic Health Record
Vitals
Student Documentation Model Documentation
128/82 mm Hg (97.3 MAP)
HP 78
99% SpO2
98.9 degrees F
FVC 3.91 L
FEV1 3.15 L
FEV1/FVC - 0.81
• Height: 170 cm
• Weight: 84 kg
• BMI: 29.0
• Blood Glucose: 100
• RR: 15
• HR: 78
• BP:128 / 82
• Pulse Ox: 99%
• Temperature: 99.0 F
Health History
Student Documentation Model Documentation
Identifying Data & Reliability
Able to state name and date of birth that matches
EHR records. Oriented x3.
(For the record, I did stop before starting asking
questions. There should be a lapse in time. I was
documenting)
Ms. Jones is a pleasant, 28-year-old African
American single woman who presents for a preemployment physical. She is the primary source of
the history. Ms. Jones offers information freely and
without contradiction. Speech is clear and coherent.
She maintains eye contact throughout the interview.
General Survey
Ms. Jones is a 28 year old obese, African American
woman who is clearly able to keep up with her ADLs.
Her hair is braided, her clothes are clean, she seems
to be able to keep up with hygiene. She does not
seem to be in any acute distress.
Ms. Jones is alert and oriented, seated upright on
the examination table, and is in no apparent distress.
She is well-nourished, well-developed, and dressed
appropriately with good hygiene
[Solved] NR 509 Shadow Health Documentation / Electronic Health Record 2017
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- Submitted On 11 Aug, 2021 05:58:19
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