Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record.

Document Content and Description Below

Documentation / Electronic Health Record  Documentation Vitals Student Documentation Model Documentation BP 128/82 P 78 RR 15 Temp 37.2 O2 99% Weight 84kg Height 5'6" BMI 29 BS 100 • 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 Ms. Jones is a pleasant 28 year old African American female who presents to the clinic today for a physical for employment. Pt's responses are appropriate, maintains eye contact throughout exam. Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment 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 [Show More]

Last updated: 1 year ago

Preview 1 out of 12 pages