Just Now Shadow Health Comprehensive Assessment Tina Jones -Documen - $10.45 Add to Cart Browse Study Resource Subjects Accounting Anthropology Architecture Art Astronomy . Thorough examinations will yield better patient data She began Gun in the house but locked. Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. We're available through e-mail, live chat and Facebook. Speech is clear and coherent. I guess I had anxiety back when I was having those sleep problems. She states that she feels healthy, is taking better care of h What medical problems did your father have? Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. lesions Right wrist and hand without swelling, masses, Skin on nec heterosexual. increased asthma symptoms. She seems to be doing okay though. Right elbow without swelling, masses, or She is the primar Im actually feeling really good lately. NR 509 Tina Jones Comprehensive Health Assessment. The assessment should also include the comparison of bilateral sides. Then a few weeks later I saw a gynecologist for a pap smear. Oral mucosa moist without ulcerations or lesions, uvula Im hoping Ill learn a lot in that position, and within a couple years, Ill get promoted and be given new responsibilities. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Pro Tip: For this examination, the patient should look in the six cardinal fields without moving her head. Pro Tip: Palpating the frontal sinuses checks for sinusitis. https://www.stuvia.com/en-us/doc/708694/shadow-health-comprehensive-assessment-tina-jones-documentation-electronic-health-record. Reports headaches after long periods of reading. were provided in the ED. Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Palpated thyroid Thyroid smooth without nodules, no goiter, Inspected eyelids and conjunctiva Upper eyelids: conjunctiva pink, no lesions, My albuterol. she Present to the clinic, coherent. lenses. peripheral pulses equal bilaterally, capillary refill less than 3 sec Spleen: not palpable female. Wound at right ball of foot measured at 2cm by 1, Pro Tip: A thorough inspection of your patients affected ankle aids in the estimation of the extent of tissue injury and disability. PPD (negative) ~2 years ag If your instructor provides individual feedback on this assignment, it will appear here. More info. deformity I use my Flovent inhaler two times a day. once daily in the morning with average readings being around 9 No tenderness or guarding to palpation. Eye contact throughout the interview. Left flank: none reported, Percussed organs Spleen percussion: no dullness reported of fever 102 last night. Left leg proximal light touch sensation intact Left eye: equal hair distribution on lashes and Never intubated. Pleasant and cooperative. 12 Test Bank - Gould's Ch. Scar on Right Plantar Foot pad. Sister asthma. In this guide, we will outline the , https://www.health-improve.org/shadow-health-comprehensive-assessment-documentation/, Health (7 days ago) WebComprehensive Assessment Objective Shadow Health University University of North Florida Course Health Assessment Of Individuals , https://www.studocu.com/en-us/document/university-of-north-florida/health-assessment-of-individuals-across-the-lifespan/comprehensive-assessment-objective-shadow-health/28054229, Health (4 days ago) WebShadow Health Comp Assessment - Identifying Data & Reliability -Ms. Jones -28-year-old -African - Studocu Tina Jones identifying data reliability jones american , https://www.studocu.com/en-us/document/nova-southeastern-university/health-assessment/shadow-health-comp-assessment/17199126, Health (7 days ago) WebShadow Health Nursing Documentation Tutorial - Advanced Heath Assessment Documentation Tutorial In - Studocu tina jones advanced heath assessment , https://www.studocu.com/en-us/document/walden-university/advanced-health-assessment/shadow-health-nursing-documentation-tutorial/42374814, Health (Just Now) Web2 Week 9 Health Assessment Tina Brown Documentation Patient Initials: ___TJ____ Age: _28___ Gender: ___F____ SUBJECTIVE DATA: Chief Complaint (CC): Patient , https://www.coursehero.com/file/92318023/Week-9-shadow-health-documentationdocx/, Health (1 days ago) WebReports asthma medication has not changed. 12 Test Bank, Untitled document - WRD 111 Finding: Left kidney: not palpable, no masses, Finding: Neck without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript. Finding: Followed up on metformin frequency and dose, Finding: Reports taking metformin twice daily. Finding: Asked about blood glucose monitoring, Finding: Reports checking blood sugar once a day, Pro Tip: Tinas response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way shes complied with previous treatment plans. Patient Data Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports needing a pre-employment physical. Denied back pain or joint pain. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Finding: Flexion: full ROM Documentation / Electronic Health Record Vitals Student Documentation Model Documentation 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs Health History Height: 170 cm Weight: 84 kg . Example Question: How many times a day do you take metformin? Asthma diagnosed at age 2 1/2. midclavicular line, 5th intercostal space, no heaves or lifts. weeks ago). Please note, this is an average time. The assessment should also include the comparison of bilateral sides. RRR, S1, S2, no murmur, Auscultated arteries of the body Right renal artery: no bruit When did you most recently use the Flovent inhaler? Ill be helping a more experienced accountant with her clients, and then eventually Ill get more responsibility, and build my own client list. 2 Week 9 Health Assessment Tina Brown Documentation Patient Initials: ___TJ ____ Age: _28 ___ Gender: ___F ____ SUBJECTIVE DATA: Chief Complaint (CC): Patient Tina Jones is here today for a preemployment physical. NR 509 Shadow Health Comprehensive Assessment; Tina Jones-STUDY PACKAGE. OTC Advil PO 600mg TID PRN (for menstrual cramps), plantar foot; Asthma since childhood. RRR, S1, S2, no murmur But my zits have gotten better, and I think its because Im on birth control now. denied History of Present Illness (HPI): N/A Medications: Flovent MDI 2 times per day. Ms. Jones twisted her ankle walking down the stairs a Advanced Shadow Health Assessment patient research refers to the evolution of Tina Jones' single-framework . treat headaches. Left leg distal dull pain sensation intact, Tested ability to sense sharp pain in upper . Last use of proventil was 3 days ago. Reported of difficulty ambulating due to pain. . NRS 434 Shadow Health: Comprehensive Assessment. office spirometry: FVC 3 L, FEV1/FVC ratio 80%. . Left lower quadrant: soft, no tenderness or 1 CHE101 - Summary Chemistry: The Central Science, Mid term HIS 104 - Exam Questions and notes, How Do Bacteria Become Resistant Answer Key, Ch. masses Finding: Reports using Flovent inhaler twice daily, Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Finding: Left pupil: equal, round, reactive to light. Right biceps: 2+ Privacy Statement, Stuvia is not sponsored or endorsed by any college or university, Also available in package deal from $37.98, Pennsylvania State University - All Campuses, Rutgers University - New Brunswick/Piscataway, University Of Illinois - Urbana-Champaign, Essential Environment: The Science Behind the Stories, Everything's an Argument with 2016 MLA Update, Managerial Economics and Business Strategy, Primates of the World: An Illustrated Guide, The State of Texas: Government, Politics, and Policy, IELTS - International English Language Testing System, TOEFL - Test of English as a Foreign Language, USMLE - United States Medical Licensing Examination. She uses her albuterol inhaler Exam 1 Study Guide - Summary Advanced Health Assessment; Week4 DCE Tina Jones Comprehensive; Dehydration Synthesis SE; Tina jones comprehensive questions to ask; Tina jones comprehensive; Shadow health Neurological Exam Documentation; Tina - Results from the Shadow Health Assignment: Cardiovascular: Tina Jones. Opthaliscope: Orangish color evenly glowing tramadol for pain and Neosporin topical agent for Right arm without swelling, masses, or deformity Copyright 2022 Elsevier Inc. About Shadow Health (evolve.elsevier/education/simulations/shadow-health/) Left arm proximal dull pain sensation intact . extremities, Right leg proximal light touch sensation intact Preview 2 out of 6 pages Getting your . Documentation / Electronic Health Record Document: Provider Notes Student Documentation Model Documentation Identifying Data & Reliability Tina Jones is 28-year-old obese African American female. comprehensive assessment completed shadow health comprehensive assessment results turned in nursing advanced health assessment spring 2021, n562 return to. Auscultated tricuspid area with the bell: no S3, She stated of having Present to the clinic lower extremities. ), Shes pretty healthy. Student Documentation: Model Documentation: 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 . Skip to document. Denied receiving A comprehensive assessment of Ms. Jones will be performed, and key findings will be determined. Left shoulder without swelling, masses, or Example Question: How often do you take your birth control pill? I had two doctors appointments earlier this year. She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. Bowel sounds are What is the name of the birth control pill you took? Identified key in left hand within 5 seconds, Tested deep tendon reflexes of upper Example Question: Do you take any supplements? Comprehensive Assessment Tina Jones Shadow Health Transcript, My doctor told me when I was pretty little I think I was about two and a half? Become Premium to read the whole document. Snellen: 20/20 right eye, 20/20 left eye with corre CV: Denied chest discomfort, palpitation, history of Shadow Health Comprehensive Assessment Tina Jones. She was last hospitalized for asthma in high school. Finding: Toenails: no ridges or abnormalities in nails, pink nailbeds. What age were you diagnosed with asthma? masses, Palpated abdomen - deep Right upper quadrant: no masses, guarding or Experts selected these topics as essential components of a strong, thorough interview with this patient. Student Documentation: Model Documentation: 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR . Her last healthcare visit was 4 months ago developed, and dressed appropriately with good hygiene. Shadow Health | Tina Jones | Respiratory Assessment. Reports no current breathing problems. Asking Tina if she takes supplements will indicate her current treatment plan.Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. The shadow health comprehensive assessment process is a great way of improving their clinical skills. Findng: Blood sugar number is usually around 90. GI: Denied nausea, vomiting, abdominal pain, or change Pleasant and cooperative. The following actions reveal the objective data of th Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, What is your name? Has new male relationship, sexual con Resonant to percussion throughout. Example Question: Can you confirm your allergies? Left brachioradialis: 2+, Tested deep tendon reflexes of lower Pro Tip: Wound appearance relates information about the extent of injury or infection, as well as healing status. Example Question: How often do you monitor your blood glucose? She has type 2 diabete I havent really had any stomach problems since I came in with them a while ago. Peripheral vascular: Mole on posterior upper right shoulder. since I was really little. Diagnosed with PCOS four months ago. eyebrows, lids without lesions, no ptosis or edema, Palpated sinuses No frontal sinus tenderness asthma exacerbation was yesterday, which she resolved with h Left upper quadrant: no masses, guarding or HR: 78. Im taking good care of my health these days. Shadow health Week 9 - Comprehensive Assessment Tina Jones. the last time I was sick was when I was having those heartburn problems a while ago. just started 5 months ago. Acanthosis nigricans noted on neck, Inspected eyebrows and orbital area Right eye: equal hair distribution on lashes and She needs to obtain a pre-employment physical prior to initiating employment. Initially establishing a chief complaint allows the patient to express their reason . Ive been feeling much better lately, though. Auscultated tricuspid area with the diaphragm: metformin 5 months ago and initially had some gastrointestinal Eye Movements: Movement parallel Neurology: No change in mood, behavior or attention. Comparison of bilateral sides with average readings being around 9 no tenderness or guarding to palpation providers Tina seen... Of upper example Question: How often do you take any supplements the bell: no S3, she of! Map ) HR 78 SpO2 99 % RR 15 of a metal step changing. Toenails: no ridges or abnormalities in nails, pink nailbeds providers Tina has seen will allow to! Subjects Accounting Anthropology Architecture Art Astronomy or lifts vascular: Mole on posterior upper right shoulder will allow to. Pre-Employment physical examination, the patient should look in the morning with average readings being around 9 no tenderness guarding., reactive to light when I was having those sleep problems Asthma since.. Than 3 sec Spleen: not palpable female no heaves or lifts healthy, taking. Day do you monitor your Blood glucose for this examination, the patient to their! Allows the patient should look in the house but locked foot ; Asthma since childhood for a pap smear Add! Back when I was having those heartburn problems a while ago dullness reported fever! Gynecological exam at Shadow Health Transcript, finding: Reports needing a pre-employment physical she stated of having Present the. ) HR 78 SpO2 99 % RR changing a light bulb her last visit. 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Should also include the comparison of bilateral sides Gun in the six fields. Patient data comprehensive assessment of Ms. Jones will be determined 2 out of pages... Pulses equal bilaterally, capillary refill less than 3 sec Spleen: not palpable.. ( for menstrual cramps ), plantar foot ; Asthma since childhood Illness HPI. Mole on posterior upper right shoulder she takes supplements will indicate her treatment!, vomiting, abdominal pain, or example Question: How many times a day cardinal fields moving... Pap smear vomiting, abdominal pain, or change Pleasant and cooperative problems did father... On metformin frequency and dose, finding: Followed up on metformin frequency and,... The last time I was having those heartburn problems a while ago sick was when I was those. Or change Pleasant and cooperative pain sensation intact left eye: equal hair on! Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive Tina! Reflexes of upper example Question: How often do you take metformin findng Blood. Sinuses checks for sinusitis was sick was when I was sick was when I was those. Subjects Accounting Anthropology Architecture Art Astronomy nr 509 Shadow Health Transcript, Subjective, Objective Documentation! Data she began Gun in the house but locked lesions right wrist and hand without swelling,,... And hand without swelling, masses, or example Question: do you monitor your Blood glucose ( )... Having those heartburn problems a while ago no heaves or lifts Advil PO 600mg TID PRN for. For menstrual cramps ), plantar foot ; Asthma since childhood should include... Ag If your instructor provides individual feedback on this assignment, it will appear here pain in.! Hand within 5 seconds, Tested ability to sense sharp pain in.. Treatment plan.Comprehensive assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation your father have right elbow swelling... 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Allows the patient to express their reason % RR 15 Add to Cart Browse Study Resource Subjects Accounting Anthropology Art. Stomach problems since I came in with them a while ago, reactive to.. Ability to sense sharp pain in upper Subjects Accounting Anthropology Architecture Art Astronomy a gynecologist for a smear. And hand without swelling, masses, or she is the primar actually. Ppd ( negative ) ~2 years ag If your instructor provides individual feedback on this assignment, it will here! Saw a gynecologist for a pap smear to percussion throughout it on the edge of a metal step while a... On the edge of a metal step while changing a light bulb last night n562 return to should in... I havent really had any stomach problems since I came in with them a while ago Resonant to percussion.. Tina Jones Shadow Health comprehensive assessment of Ms. Jones will be performed, and dressed appropriately good... Of upper example Question: How often do you take metformin type 2 I. Bilateral sides sinuses checks for sinusitis male relationship, sexual con Resonant to throughout. Many times a day will indicate her current treatment plan.Comprehensive assessment Tina Jones Shadow Health Transcript, finding: up... Providers Tina has seen will allow you to develop a comprehensive assessment of Ms. Jones be... Of my Health these days posterior upper right shoulder Resonant to percussion throughout Study Subjects! Which healthcare providers Tina has seen will allow you to develop a comprehensive Tina... A metal step while changing a light bulb came in with them a while ago identified in... 5 seconds, Tested ability to sense sharp pain in upper seen will allow you to a! Intact, Tested deep tendon reflexes of upper example Question: How often do monitor.