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Documentation / Electronic Health Record: Vitals
Documentation / Electronic Health Record: Vitals
Documentation
Vitals
Student Documentation Model Documentation
Health History
Student Documentation Model Documentation
Identifying Data & Reliability Ms. Jones is a pleasant, 28-year-old African American single
woman who presents for a pre-employment physical. She is the
Ms. Jones is a pleasant 28 year old African American female who primary source of the history. Ms. Jones offers information freely
presents to the clinic today for a physical for employment. Pt's and without contradiction. Speech is clear and coherent. She
responses are appropriate, maintains eye contact throughout exam. maintains eye contact throughout the interview.
General Survey Ms. Jones is alert and oriented, seated upright on the examination
table, and is in no apparent distress. She is well-nourished, well-
Pt in no apparent distress, alert and oriented x 4, calm and developed, and dressed appropriately with good hygiene.
Student Documentation Model Documentation
Allergies • Penicillin: rash • Denies food and latex allergies • Allergic to cats
and dust. When she is exposed to allergens she states that she has
PCN- skin rash Cats- exacerbates asthma Dust-exacerbates asthma, runny nose, itchy and swollen eyes, and increased asthma
itchy symptoms.
Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when
she is around cats. Her last asthma exacerbation was three months
ago, which she resolved with her inhaler. She was last hospitalized
for asthma in high school. Never intubated. Type 2 diabetes,
Medical History diagnosed at age 24. She began metformin 5 months ago and
initially had some gastrointestinal side effects which have since
Asthma- diagnosed at 2 years old, uses daily and rescue inhaler, dissipated. She monitors her blood sugar once daily in the morning
last exacerbation 3 months ago Diabetes- diagnosed at 24 years with average readings being around 90. She has a history of
old, currently takes Metformin with gasiness upon inital use wtih hypertension which normalized when she initiated diet and
no current side effects, pt taking BS QD, readings on average 90. exercise. No surgeries. OB/GYN: Menarche, age 11. First sexual
HTN- controlled with diet and exercise Polycysic Ovarian encounter at age 18, sex with men, identifies as heterosexual.
Syndrome- diagnosed approximately 4 months ago, controlled with Never pregnant. Last menstrual period 2 weeks ago. Diagnosed
birth control, menstrual cycles normal and regular. with PCOS four months ago. For the past four months (after
initiating Yaz) cycles regular (every 4 weeks) with moderate
bleeding lasting 5 days. Has new male relationship, sexual contact
not initiated. She plans to use condoms with sexual activity. Tested
negative for HIV/AIDS and STIs four months ago.
Health Maintenance Last Pap smear 4 months ago. Last eye exam three months ago.
Last dental exam five months ago. PPD (negative) ~2 years ago.
Since last encounter at teh clinic pt has had an OBGYN exam Immunizations: Tetanus booster was received within the past year,
approximately 4 months ago, pt had had an eye exam influenza is not current, and human papillomavirus has not been
approximately 3 months ago. Pt states she is now exercising received. She reports that she believes she is up to date on
regularly, has been eating healthier, and has cut back on her childhood vaccines and received the meningococcal vaccine for
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Social History Never married, no children. Lived independently since age 19,
currently lives with mother and sister in a single family home, but
Pt just graduated college with an accounting degree, never married, will move into own apartment in one month. Will begin her new
no children, pt in a relationship with a male, pt denies smoking or position in two weeks at Smith, Stevens, Stewart, Silver, &
drug use, occasional alcohol with friends. Pt likes to read, currently Company. She enjoys spending time with friends, reading,
lives at home with her mother and sister but has plans to move out attending Bible study, volunteering in her church, and dancing.
next month. Tina is active in her church and describes a strong family and
social support system. She states that family and church help her
cope with stress. No tobacco. Cannabis use from age 15 to age 21.
Reports no use of cocaine, methamphetamines, and heroin. Uses
alcohol when “out with friends, 2-3 times per month,” reports
drinking no more than 3 drinks per episode. Typical breakfast is
frozen fruit smoothie with unsweetened yogurt, lunch is vegetables
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Review of Systems - General No recent or frequent illness, fatigue, fevers, chills, or night sweats.
States recent 10 pound weight loss due to diet change and exercise
General: no weakness, fatigue or fevers. Positive weight loss of 10 increase.
pounds. Skin: no rashes, lesions, dry skin, ithcing or clor changes,
no dandruff, or changes in nails. HEENT: No headaches, eye pain,
dizziness or blurry vision. No ear pain or drainage. No mouth or
teeth pain. No sinus pressure, sneezing, runny nose, change in
smell. Pt does wear prescription glasses. Cardiac: No chest pain,
palpitaitons, or edema. Pt has history of HTN, now controlled.
Respiratory: No SOB, difficulty breathing, or wheezing. Pt has a
diagnosis of asthma. GI: No diarhhrea, constipation, vomiting or
nausea. No abdominal pain. GU: No issues with urination. Neuro:
No dizziness, motor issues, lack of coordination, numbness or
tingling sensations. Musculoskeletal: No muscle pain or joint
inflammation. No recent injuries or deformities, no difficulty or
Student Documentation Model Documentation
HEENT
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Respiratory
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Subjective
Reports no shortness of breath, wheezing, chest pain, dyspnea, or
Pt denies shortness of breath, difficult breathing, wheezing or
cough.
cough. Pt has history of asthma. Denies sinus pressure or
rhinnorhea.
Objective
Peak flow x3: FVC 3.91, FEV 3.15= FEV1/FVC ratio of 80.5% Pt Chest is symmetric with respiration, clear to auscultation bilaterally
in no obvious distress, breathing unlabored, chest symmetrical, rise without cough or wheeze. Resonant to percussion throughout. In
and fall of chest even. Breath sounds clear and equal bilaterally in office spirometry: FVC 3.91 L, FEV1/FVC ratio 80.56%.
all fields. Tympanic resonance to percussion anterior and posterior
chest with no dullness. Fremitus normal.
Cardiovascular
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Subjective
Reports no palpitations, tachycardia, easy bruising, or edema.
Pt denies chest pain, palpitaitons, or edema. No history of anemia
or easy bruising.
Objective
Heart rate is regular, S1, S2, without murmurs, gallops, or rubs.
S1, S2 heard with normal rate and rythm, no murmurs or gallops Bilateral carotids equal bilaterally without bruit. PMI at the
noted on auscultation. Pulses present in all extremeties 2+, no midclavicular line, 5th intercostal space, no heaves, lifts, or thrills.
thrills. No edema in extremities, PMI MCL 5th intercostal space. Bilateral peripheral pulses equal bilaterally, capillary refill less
Carotid pulsespresent with no bruit. Capillary refill <3 sec in all than 3 seconds. No peripheral edema.
extremities. No abdominal, iliac, renal or femoral bruits. No JVD.
Abdominal
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Subjective
Gastrointestinal: Reports no nausea, vomiting, pain, constipation,
Pt denies any nausea, vomiting, diarrhea, constipation, abdominal diarrhea, or excessive flatulence. No food intolerances.
pain or discomfort. Reports eating healthier but no change in Genitourinary: Reports no dysuria, nocturia, polyuria, hematuria,
appetite. No difficulty urinating or excessive urinating. Denies flank pain, vaginal discharge or itching.
bowel or bladder dysfunction.
Musculoskeletal
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Subjective
Reports no muscle pain, joint pain, muscle weakness, or swelling.
Pt denies no joint or muscle pain, no weakness or edema.
Objective
Strength 5/5 bilateral upper and lower extremities, without
No obvious injuries or deformities. No edema or lacerations. Full swelling, masses, or deformity and with full range of motion. No
ROM in neck, shoulders, arms, wrists, ankles, hips, spin, knees. pain with movement.
Strenght 5+ bilaterally all extremities.
Neurological
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Subjective
Reports no dizziness, light-headedness, tingling, loss of
Pt denies any numbness or tingling sensations, denies issues with
coordination or sensation, seizures, or sense of disequilibrium.
coordination and gait. No dizziness, history of seizures. Pt denies
any history of head injuries. Pt denies any loss of sensation.
Objective
Subjective
Reports improved acne due to oral contraceptives. Skin on neck
Pt denies rashes, bruising, or lesions. States darkness around neck has stopped darkening and facial and body hair has improved. She
is diminishing since birth control and metformin. Denies dandruff reports a few moles but no other hair or nail changes.
or hair loss. Denies changes in nail beds or brittle nails.
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Objective
No obvious injuries, lacerations, rashes, dandruff, or bruising. Pt's Scattered pustules on face and facial hair on upper lip, acanthosis
hair well groomed with even hair distribution. No nail deformities nigricans on posterior neck. Nails fre
noted in all extremities, clear with no ridges. Excessive hair growth
on umbilicus, thin hair growth on upper lip.