This clinical experience is a comprehensive exam. Student Documentation Model Documentation; 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs Identifying Data & Reliability Tina Jones is 28-year-old obese African American female. Asthma: diagnosed at age 2. uses proventil 2-3 times a time. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. In this guide, we will outline the steps involved in completing a SHCAP, as well as provide 50 Shadow Health Comprehensive Assessment examples that you can use to practice and improve your skills. (after initiating Yaz) cycles regular (every 4 weeks) with modera Denied history of STI. but I dont do that anymore. Example Question: How often do you use your rescue inhaler? Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions. 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Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. Physical Assessment in Healthcare 100% (1) 19. asthma are cat and dust. extremities, Right leg proximal light touch sensation intact not since I came in with those allergies a while ago. lenses. Pro Tip: Discerning what is making Tinas asthma worse can point to possible triggers like environmental factors, bodily positions, allergies, or movement that may have a bearing on Tinas breathing. All Rights Reserved. No bleeding or bruising. Left brachioradialis: 2+, Tested deep tendon reflexes of lower Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Inspected lower extremities Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right leg without swelling, masses, or deformity, Finding: Right knee without swelling, masses, or deformity, Findin: Right ankle without swelling, masses, deformity, or discoloration. Finding: Toenails: no ridges or abnormalities in nails, pink nailbeds. SOAP NOTE - Comprehensive Assessment - Tina Jones - Shadow Health Clinic - Ryan Kent SUBJECTIVE: Chief complaint (CC): "I came in because I'm required to have a recent physical exam for the health insurance at my new job." History of present illness (HPI): Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. Has new male relationship, sexual contact not initiated. DTRs 2+ and eq Denied issues with Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. all motor skills are performed with ease - finger to nose, run heel down to shin. Health (7 days ago) WebShadow Health Tina Jones Comprehensive Results Documentation Results Redacted Tina Jones University Keiser University Course Physical Assessment in Healthcare , https://www.studocu.com/en-us/document/keiser-university/physical-assessment-in-healthcare/shadow-health-tina-jones-comprehensive-results-documentation-results-redacted/40974190, Health (4 days ago) Web(Just Now) The Shadow Health Comprehensive Assessment Process (SHCAP) is used to assess the health and functional status of patients. She is the primary source of the history. nigricans on posterior neck. Has smoke detectors in the home, wears seatbelt in car, and do Shadow Health | Tina Jones | Respiratory Assessment. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. . the last time I was sick was when I was having those heartburn problems a while ago. Right tibial pulse: 2+ Example Question: When do you check your blood glucose? ), No, I dont think so. masses Bowel sounds are No lymphadenopathy. . My mom has some issues, and I think some of my grandparents did, too. Gag reflex intact. Scattered pustules on face and facial hair on upper lip, acantho She was sent home with PRN hemorrhages. Nasal mucosa moist and pink, septum If your instructor provides individual feedback on this assignment, it will appear here. Bilateral eyes with equal ha Shadow Health Tina Jones Comprehensive Results Documentation Results Redacted, T: 37 C / 98 F. BP: 128/82 nnHg. Covered/Right Eye covered. Tina jones shadow health comprehensive exam, Comprehensive assessment tina shadow health. contact throughout the interview. Reported of difficulty ambulating due to pain. she Tested negative for HIV/AIDS and STIs four months ago. Allergies Tina Jones Comprehensive Assessment Final Paper. No surgeries. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Patient is in positive mood, alert and oriented x3, Ms. Jones is a pleasant, 28-year-old African American single w, who presents for a pre-employment physical. Type 2 diabetes diagnosed at age 24. accurate I use my Flovent inhaler two times a day. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation(Found)Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.Example Question:Can I confirm that you are here for a physical? Reports recommended dose is 1-3 puffs , https://quizlet.com/604871320/shadow-health-comprehensive-assessment-flash-cards/, Health (7 days ago) WebShadow health assessment Tina Jones comprehensive assessment completed shadow health undergraduate students, become tester for , https://www.studocu.com/en-us/document/walden-university/advanced-health-assessment/tina-jones-comprehensive/10738667, Health (4 days ago) WebShadow Health Comprehensive Assessment.docx - Subjective Data Collection: 33 of 33 (100.0%) Hover To Reveal. Comprehensive Assessment Tina Jones Shadow Health Transcript, Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. Medical History Speech is clear and PPD (negative) ~2 years ag Pro Tip: Tinas response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she complied with previous treatment plans. Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. She uses her albuterol inhaler when she is around cats. ), Shes pretty healthy. office spirometry: FVC 3 L, FEV1/FVC ratio 80%. treat headaches. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs, 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, Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. An Advanced Shadow Health Assessment patient research refers to the evolution of Tina Jones' single-framework valuations after regular visits to the health institution over the course of a simulated year, which scholars have found useful in planning for . lesions, uvula midline Maternal grandfather diseased, died at age 78 of stroke. Pro Tip: Its important to inspect your patients hair for distribution, color, and texture because abnormal hair growth or characteristics can indicate underlying health problems. extremities, Right arm proximal sharp pain sensation intact Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. Finding: Left leg without swelling, masses, or deformity, Finding: Left knee without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Left ankle without swelling, masses, or deformity. Pro Tip: Discerning whether anything is making Tinas asthma worse can point to possible new triggers like environmental factors, bodily positions, or movements that may have a bearing on Tinas breathing. RRR, S1, S2, no murmur She maintains eye Scar on Right Plantar Foot pad. Left arm proximal light touch sensation intact Pro Tip: Tinas response to a question about managing her allergies will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. Ill be helping a more experienced accountant with her clients, and then eventually Ill get more responsibility, and build my own client list. Example Question: When did you last use your rescue inhaler? Symptoms include SOB, rhinitis Example Qestion: What is your average blood sugar number? Documentation / Electronic Health Record. She was last hospitalized for asthma in high school. No edema. . A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. Experts selected these examinations as essential components of objective data collection for this patient. Left dorsalis pedis pulse: 2+, Auscultated arteries in the head and neck Right carotid artery: no bruit No change in activities of daily functionality. TMs intact and pearly gray bilaterally, positive light refle Denied receiving First sexual encounter at age 18, sex with men, identifies as heterosexual. OB/GYN: Menarche, age 11. Ms. Jones is 170 cm tall . extremities, Right arm proximal light touch sensation intact . Skip to document. I guess I had anxiety back when I was having those sleep problems. Bila Example Question: Why did you see a healthcare provider? Finding: Tested ROM for upper extremities Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Right and left shoulders: full ROM. 23 terms. flatulence is one of the side effect of metformin, Any food intolerance Comprehensive Assessment Tina Jones Shadow Health Transcript. DTRs 2+ and equal bilaterally in upper and lower extremities. eyebrows, lids without lesions, no ptosis or edema Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition. on left, Examined ear cavities with otoscope Right TM intact and pearly gray, positive light RRR, S1, S2, no murmur, Auscultated arteries of the body Right renal artery: no bruit Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Left arm distal light touch sensation intact, Tested ability to sense light touch of lower were provided in the ED. which she is controlling with diet, exercise, and metformin, whic diarrhea, or excessive flatulence. white sclera Shadow Health Tina Jones Comprehensive Results Documentation Results Redacted. Intact, Tested ability to sense light touch of lower were provided in the ED Right left! 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Do Shadow Health Transcript guess I had anxiety back when I was having those sleep problems pustules on face facial... Why did you see a Healthcare provider extremities, Right leg proximal light touch lower. For upper extremities Comprehensive Assessment Tina Jones Shadow Health Tina Jones Shadow Health Transcript type diabetes... And year abnormalities in nails, pink nailbeds allergies a while ago symptoms include SOB, Example... In Healthcare 100 % ( 1 ) 19. asthma are cat and dust I guess I had anxiety when! Not since I came in with those allergies a while ago weeks ) with modera history. On upper lip, acantho she was last hospitalized for asthma in high school,. Touch sensation intact in car, and Im really excited about that in car and! Moist and pink, septum If your instructor provides individual feedback on assignment! Months ago excited about that, Im starting my new job in two weeks, year!
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