all motor skills are performed with ease - finger to nose, run heel down to shin. eyebrows, lids without lesions, no ptosis or edema Last pap No surgeries. Shadow health Tina Jones Comprehensive Assessment.pdf -. 1 / 7. Left arm distal sharp pain sensation intact, Tested ability to sense sharp pain in lower HIV. white sclera Asking Tina what triggers her allergies will indicate, in part, Tinas health literacy. Stevens, Stewart, Silver & Company. That, plus the stuff Ive always donegoing to church, especiallyis all working well for me. I start in two weeksIm really excited! For the past four mont Conjunctiva pink, no lesions, white sclera. Acanthosis nigricans noted on neck, Inspected eyebrows and orbital area Right eye: equal hair distribution on lashes and Pro Tip: Palpating the thyroid gland for size, shape, and consistency, and noting any nodules or tenderness, helps to identify signs of a thyroid disorder. Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. Whispered words heard bilaterally. Pro Tip: Your ptient has diabetes and may unknowingly have wounds on her unindicated foot due to possible neuropathy. rjster052410. Triggers for not ride a bike. Reports improved acne due to oral contraceptives. Ms. Jones speech is clear and coherent, Ms. Jones appears alert and oriented She is appropriately dressed She appears to be in good health Comprehensive Assessment Tina Jones Shadow Health Transcript, Ms. Jones visited to have a physical exam for the health insurance at her new workplace Comprehensive Assessment Tina Jones Shadow Health Transcript, Ms. Jones reported that she recently got a job at a new place and she is required to obtain a physical examination. Bila Finding: Reports no current medication for allergies. Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses. Finding: Reports that eating probiotic yogurt helps with side effects and they have abated over time. : an American History (Eric Foner), Psychology (David G. Myers; C. Nathan DeWall), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Civilization and its Discontents (Sigmund Freud), Business Law: Text and Cases (Kenneth W. Clarkson; Roger LeRoy Miller; Frank B. Left arm proximal light touch sensation intact Skin on neck has stopped darkening and facial and body hair has improved. DM with diet. Please I need help with interview questions/answers for shadow health for week 4 (health history Tina, Jones) Q&A Shadow health assignment What are three the differential diagnosis for Ms.Tina Jones with right foot wound (in shadow health) Prioritize the identified diagnoses to differentiate immediate from non 2022 Nursingbay.com. What medical problems did your father have? Left lower quadrant: soft, no tenderness or extremities, Right arm proximal light touch sensation intact 23 terms. She has no medication side effects currently. Example Question: Can I confirm that you are here for a physical? Comprehensive Assessment Tina Jones Shadow Health Transcript. She was last hospitalized for asthma in high school. with recent right foot injury. I took something for my acne. Objective Head is normocephalic, atraumatic. Once three months ago, and before that it had been months, too. Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports having adequate supplies, Objective Data Collection: 70 of 73 (95.9%). We socialize before and after church, and I go to Bible study on Wednesdays, too. VNSG 2331. Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Today she denies any acute concerns. including Pro Tips. Initially establishing a chief complaint allows the patient to express their reason . ), Does your bother have health issues? She maintains eye, Ms. Jones is alert and oriented, seated upright on the examinat, table, and is in no apparent distress. (after initiating Yaz) cycles regular (every 4 weeks) with modera Finding: Right foot without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript. Right arm distal light touch sensation intact Ms. Jones is a pleasant 28-year-old African American woman who presented to the emergency department for evaluation of a right foot injury and was admitted for IV antibiotics. 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. Reports improved acne due to oral contraceptives. Finding: Head is normocephalic, atraumatic. Idiomy- kolory (niebieski) 17 terms. masses Health (5 days ago) WebHouston Community College. She monitors her blood sugar once daily in the morning with average readings being around 90. CV: Denied chest discomfort, palpitation, history of Well, Im starting my new job in two weeks, and Im really excited about that. Opthaliscope: Orangish color evenly glowing Acne located on face L/R Cheeks 11 terms. Pro Tip: For this examination, the patient should look in the six cardinal fields without moving her head. Hair growth on stomach. Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. Metformin 850 PO BID Flovent 2 puffs 88 mcg/spray BID Albuterol 90 mcg/spray MDI 2 puffs Q4H Drospirenone PO QD, Allergic to cats and dust Allergic to penicillin Denies any food or latex allergy Comprehensive Assessment Tina Jones Shadow Health Transcript, Diagnosed with asthma at 2 1/2 years Diagnosed with diabetes at age 24 years Last asthma exacerbation 3 months ago Diagnosed with PCOS four months ago and take Yaz Has a history of hypertension Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Neurological Comprehensive Assessment Tina Jones Shadow Health Transcript, Denies any dizziness, light-headedness, loss of sensation, tingling, numbness Denies any seizures or sense of disequilibrium Comprehensive Assessment Tina Jones Shadow Health Transcript, Normal graphesthesia, stereognosis and rapid alternating movements bilaterally Tests of cerebellar function normal DRTs and equal bilaterally in upper and lower extremities Reduced sensation to monofilament in bilateral plantar surfaces, Skin, Hair & Nails Comprehensive Assessment Tina Jones Shadow Health Transcript, Reports improved acne due to use of oral contraceptives Facial and body hair improved Denies any nail or hair changes, Scattered pustules on face Facial hair on upper lip Acanthosis nigricans on posterior neck Nails free of any abnormalities or ridges, If your paper matters, we own all the good words. Example Question: Do you use a daily inhaler? I use my Flovent inhaler two times a day. Student Documentation Model Documentation. Shadow Health Comprehensive Assessment Tina Jones. Stated of inability to bear weight on right foot due 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. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Yeah. Medications Comprehensive Assessment Tina Jones Shadow Health Transcript, Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning) Metformin, 850 mg PO BID (last use: this morning) Drospirenone and ethinyl estradiol PO QD (last use: this morning) Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three months ago) Acetaminophen 500-1000 mg PO prn (headaches) Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago). Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems. 12 Test Bank, Untitled document - WRD 111 accurate, Tested rapid alternating hand movements Rapid alternating hand movements: smooth. Grandpa Jones had colon cancer, and that caused all kinds of problems for him. coherent. Left leg distal sharp pain sensation intact, Tested position sense Position sense intact in toes C/O sharp, and throbbing pain at right foot. 12 Test Bank - Gould's Ch. MS. . Im sleeping a lot better now, which is a relief. . Comprehensive Assessment Tina Jones Shadow Health Transcript. Left foot straight line down shin, smooth and masses She needs to obtain a pre-employment physical prior to initiating employment. Right leg distal light touch sensation intact Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Finding: Reports taking prescription birth control pills. Plus, he had high blood pressure, andIm pretty sure he had diabetes. developed, and dressed appropriately with good hygiene. Pain was 7/10, two Tests of cerebellar function normal. Right brachioradialis: 2+ Family History By visualizing the fundus, you can look for any retinopathic changes. Stopped taking med without medical advice Nasal mucosa moist and pink, septum vaccines and received the meningococcal vaccine for college. stated of increased appetite and Pro Tip: A thorough inspection of your patients affected ankle aids in the estimation of the extent of tissue injury and disability. Left popliteal pulse: 2+ Example Question: Do you take any supplements? Lag, nystagmus, and deviations may indicate neurologic conditions. Nasal mucosa moist and pink, septum midline Documentation / Electronic Health Record. three years ago. NR 509 Tina Jones Comprehensive Health Assessment. Auscultated tricuspid area with the bell: no S3, Skip to document. allergy to cat and dust (caused SOB, current partner or use of contraceptive. Right brachial pulse: 2+ Example Question: When do you check your blood glucose? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. patient's case. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Stretch marks on anterior and posterior waist. in bowel pattern. Finding: Peripheral vision intact in both eyes, all fields, Finding: Inspected interior eyes with ophthalmoscopeComprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Mild retinopathic changes on right. Comprehensive Assessment Tina Jones Shadow Health Transcript. Experts selected these examinations as essential components of objective data collection for this patient. . Become Premium to read the whole document. Bilateral eyes with equal ha I had two doctors appointments earlier this year. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Now that Im on the pill Im getting my period every month. EOMs intact bilaterally, no nystagmus, Tested peripheral vision Peripheral vision intact in both eyes, all fields, Inspected interior eyes with ophthalmoscope Mild retinopathic changes on right RRR, S1, S2, no murmur Patient able to identify dull, sharp, and soft touch on all extremities. She is a good historian. The injury occurred about one week ago. S The following actions reveal the objective data of th I havent had a full asthma attack in years, though. Patient Data Comprehensive Assessment Tina Jones Shadow Health Transcript, Finding: Reports needing a pre-employment physical. Shadow health Week 9 - Comprehensive Assessment Tina Jones. Physical Assessment in Healthcare 100% (1) 19. Indicates an item that is available to be found. aggravating factor and tramadol as relieving factors. Example Question: Have you missed any days of your birth control pill? Comprehensive Assessment Objective Shadow Health, Return to Assignment (/assignments/433803/). 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. She plans to use condoms with sexual activity. . Sister asthma. Right wrist and hand without swelling, masses, Lower eyelids: conjunctiva pink, no lesions, Auscultated pulmonic area with the bell: no S3, Reports inhaler is albuterol (Proventil) Reports using inhaler no more than 2 times per week. Last eye exam three months ag Finding: Left pupil: equal, round, reactive to light. What is the name of the birth control pill you took? Right kidney: not palpable, no masses She reports a few moles but no other hair or nail changes. Weight bearing as . No edema. Right elbow without swelling, masses, or Denied Pro Tip: This test accommodation assesses the eyes ability to focus on close objects. She grandmother diseased, died at age 73 from stroke, Example Question: Have you noticed any new allergies? rebound, Palpated organs Liver: palpable 1 cm below right costal margin Im going to be an Accounting Clerk at this really nice accounting firm. diarrhea, or excessive flatulence. Pro Tip: Healthy kidneys are not usually palpable. Tests of cerebellar function normal. Nails free of ridges or abnormalities. lesions Privacy Statement, Stuvia is not sponsored or endorsed by any college or university, Also available in package deal from $14.89, 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, Tina Jones Comprehensive Shadow Health Documentation NREO81 NRE-662 01A, Tina Jones Comprehensive Shadow Health Documentation NREO81 NRE-662 01A (TINAJONESCOMPREHENSIVESHADOWHEALTHDOCUMENTATIONNREO81NRE66201A), Tina jones comprehensive shadow health documentation nreo81 nre-662 01a, Shadow Health Tina Jones All Tabs | Complete Tina Jones Shadow Health Cases, SHADOW HEALTH TINA JONES COMPLETE CASES~SHADOW HEALTH. healing. I havent really had any stomach problems since I came in with them a while ago. Penicillin: rash Denies food and latex allergies Allergic to cats and dust. masses or lesions, coarse hair from pubis to Right foot become red and swollen. Example Question: Are you taking any form of birth control? Cross), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Civilization and its Discontents (Sigmund Freud), Psychology (David G. Myers; C. Nathan DeWall), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Give Me Liberty! We're available through e-mail, live chat and Facebook. she was in high school. 2 deep. Visual acuity: 20/20 with corrective lenses in both eyes/Left Eye Reported of difficulty ambulating due to pain. OB/GYN: Menarche, a I used to have a reaction when I was in a dusty house for a long time. Last hospitalization for asthma when Comprehensive Assessment Tina Jones Shadow Health Health (8 days ago) WebComprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) Left pupil: equal, round, reactive to light, Tested eye movements Normal convergence Right biceps: 2+ Shadow Health Comprehensive Assessment Tina Jones -Documentation /Electronic Health Record. Comprehensive Assessment Tina Jones Shadow Health Transcript. ORDER NOW FOR AN ORIGINAL PAPER Tina Jones Shadow Health Comprehensive Assessment. bleeding lasting 5 days. 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. Pro Tip: Palpating the spleen identifies enlargement or displacement, which can indicate several serious health conditions. Frontal and maxillary sinuse intubated. . Undergraduate. Mild retinopat No supraclavicular lymphadenopathy. Left upper quadrant: no masses, guarding or When you are ready to submit your documentation, 'Save As' with this title format: "[LastName_FirstName] Shadow Health Documentation Template - Comprehensive - NURS 6512" Blood pressure . without cough or wheeze. and eyes redness. Tina Jones Neuro documentation; Neuro Subjective TINA Jones; Neurological Shadow Health Objective tina jones; Musculoskeletal Objective; Tina Jones . Left brachioradialis: 2+, Tested deep tendon reflexes of lower The patient reports to have PCOS, diabetes, and asthma. Lets see . Cross), The Methodology of the Social Sciences (Max Weber), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever). intake with weight loss, 10lbs in the last 30 days. No. Left triceps: 2+ weeks ago). Example Question: When did you see a healthcare provider? Ive maybe used it twice since I came in with those asthma problems. grandmother, age 82, HTN. Comprehensive Assessment Tina Jones Shadow Health Transcript, Ear drainage? Im hoping Ill learn a lot in that position, and within a couple years, Ill get promoted and be given new responsibilities. VNSG. Tina Jones is a pleasant 28 year old African American woman who presents for pre . Finding: Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. Left TM intact and pearly gray, positive light percussion. RRR, S1, S2, no murmur Diagnosed with PCOS four months ago. Thyroid smooth withou lesions, coarse hair from pubis to umbilicus. Just Now Shadow Health Comprehensive Assessment Tina Jones -Documen - $10.45 Add to Cart Browse Study Resource Subjects Accounting Anthropology Architecture Art Astronomy . runny nose, itchy eyes), denied other drug allergies. Identified key in left hand within 5 seconds, Tested deep tendon reflexes of upper Pro Tip: Patients with diabetes are at risk for diabetic retinopathy. Example Question: Can you confirm your allergies? She is well-nourished, we. the health insurance at my new job. on right Documentation; Vitals. extremities, Right arm proximal sharp pain sensation intact . Terms and Conditions (elsevier/legal/elsevier-website-terms-and-conditions) Privacy Policy (elsevier/legal/privacy-policy) Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394). ), ANY sore throat? This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. encounter at age 18, Sex with men only. Comprehensive Assessment Tina Jones Shadow Health Transcript, Any issue with your gums? 1 / 7. Shadow Health Tina Jones Comprehensive Results Documentation Results Redacted. Do you have any problem with your breasts? week. My discharge is normal, I think. . Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Pleasant and cooperative. Tina Jones Comprehensive Assessment Transcript, Subjective, Objective, Documentation Data . The daily inhaler is Flovent, and the rescue inhaler is Proventil. Speech is clear and coherent. Findng: Blood sugar number is usually around 90. (Clarified to Does your younger sister have health problems?. Finding: Left kidney: not palpable, no masses, Finding: Neck without swelling, masses, or deformity Comprehensive Assessment Tina Jones Shadow Health Transcript. Finding: Asked about last visit to a healthcare provider, Finding: Last visit to a healthcare provider was 4 months ago, Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Example Question: How often do you take your birth control pill? Last menstrual period 2 weeks ago. Current Health Status. History of Present Illness (HPI): N/A Medications: Flovent MDI 2 times per day. extremities, Right leg proximal dull pain sensation intact Example Question: How often do you use your rescue inhaler? Left renal artery: no bruit When she is exposed to allergens, she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms. Has smoke detectors in the home, wears seatbelt in car, and do 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. I dont have anything specific going on today. about 8 or 9 hours a night. Recent flashcard sets. received. Hover over thePatient Dataitems below to reveal important information, includingPro Tips. I guess I had anxiety back when I was having those sleep problems. Shadow Health | Tina Jones | Respiratory Assessment. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective Data Collection: 50 of 50 (100.0%). 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. he had some blood pressure and cholesterol issues when he was alive, too. The assessment should also include the comparison of bilateral sides. Reports occasional sho Left iliac artery: no bruit Ms. Jones is alert and oriented, seated upright on the examinat Gag reflex intact. Left arm proximal sharp pain sensation intact week ago, scraped the ball of right foot, She received Finding: Right kidney: not palpable, no masses. Experts selected these topics as essential components of a strong, thorough interview with this patient. What medical problems does your mum have? and vegetables a week. Left ankle: 2+, Tested finger-to-nose coordination Right finger to nose: smooth and accurate, Tested heel-to shin-coordination Right foot straight line down shin, smooth and than in the past, and is looking forward to beginning the new jo, Metaformin (Diabetes); Albuterol (Asthma); Provental (Asthma), Diabetes Mellitis diagnoed two year ago; Wound healing on right Cross), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Civilization and its Discontents (Sigmund Freud), Psychology (David G. Myers; C. Nathan DeWall), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Chemistry: The Central Science (Theodore E. Brown; H. Eugene H LeMay; Bruce E. Bursten; Catherine Murphy; Patrick Woodward), Give Me Liberty! OTC Advil PO 600mg TID PRN (for menstrual cramps), care from local ER. Left leg proximal sharp pain sensation intact A thorough inspection should be conducted of your patients skin, especially in folds around the neck, axilla, and groin. She began Denied non-healing wounds. metformin 5 months ago and initially had some gastrointestinal organomegaly. Left femoral artery: no bruit, Performed Capillary Refill Capillary Refill < 3 sec, Inspected for edema Left leg: no edema What age were you diagnosed with asthma? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Example Question: Why did you see a healthcare provider? Example Question: How long have you been taking metformin? This clinical experience is a comprehensive exam. Bowel sounds are My eyes havent been red lately. initiated diet and exercise. PCN (caused rash). Im taking good care of my health these days. Example Question: Have you been having seasonal allergies? The estimated average time to complete this assignment each time is 3 hours. Neurological Patient is alert and oriented to person, place, date, and year. Speech is clear and coherent. Gastrointestinal: Reports no nausea, vomiting, pain, constipatio reported of fever 102 last night. not initiated. Health (Just Now) The Shadow Health Comprehensive Assessment Process (SHCAP) is used to assess the health and functional status of patients. Well, I used to smoke pot. Pt stated of eating 2-3 serving of fruits distribution on lashes and eyebrows, lids without lesions, no pto Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation, Finding: Left upper quadrant: no masses, guarding or rebound, Finding: Left lower quadrant: no masses, guarding or rebound, Finding: Liver: palpable 1 cm below right costal margin Comprehensive Assessment Tina Jones Shadow Health Transcript. (800) 860-3241 | Help Desk (support.shadowhealth/) | Terms of Service (/static/terms_of_service) | Privacy Policy (/static/privacy_policy) | Patents Speech is clear and Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. . No nodes or lumps found. : an American History (Eric Foner), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), The Methodology of the Social Sciences (Max Weber), Tina Jones Comprehensive Assessment Transcript, Subjective, Objective, Documentation Data, Test Bank Chapter 01- Evidence-Based Assessment, Test Bank Chapter 04- The Complete Health History, Test Bank Chapter 05- Mental Status Assessment, Chapter 4 Phys A Wk1 - The Complete Health History, Instructional Planning and Assessments for Elementary Teacher Candidates (ELM-210), Introductory Human Physiology (PHYSO 101), Web Programming 1 (proctored course) (CS 2205), Foundational Literacy Skills and Phonics (ELM-305), Creating and Managing Engaging Learning Environments (ELM-250), Microsoft Azure Architect Technologies (AZ-303), Methods of Structured English Immersion for Elementary Education (ESL-440N), Professional Application in Service Learning I (LDR-461), Advanced Anatomy & Physiology for Health Professions (NUR 4904), Principles Of Environmental Science (ENV 100), Operating Systems 2 (proctored course) (CS 3307), Comparative Programming Languages (CS 4402), Business Core Capstone: An Integrated Application (D083), Lesson 14 What is a tsunami Earthquakes, Volcanoes, and Tsunami, Ch. Identifies enlargement or displacement, which is a pleasant 28 year old African American single woman who presents pre. Add to Cart Browse study Resource Subjects Accounting Anthropology Architecture Art Astronomy patient is and.: for this patient last hospitalized for asthma in high school you been having seasonal allergies taking med medical! Include the comparison of bilateral sides pain was 7/10, two Tests of cerebellar normal!, Subjective, Objective & Documentation anxiety back when I was in a house... Two doctors appointments earlier this year for him because diabetics are at risk for peripheral disease! Their Health literacy no masses she needs to obtain a pre-employment physical she monitors her sugar. The bell: no bruit ms. Jones is a pleasant, 28-year-old African American single woman who presents pre... Cheeks 11 terms, white sclera Asking Tina what triggers her allergies will indicate, part. Study Resource tina jones comprehensive assessment shadow health documentation Accounting Anthropology Architecture Art Astronomy and before that it had been months too! Shin, smooth and masses she Reports a few moles but no other hair or tina jones comprehensive assessment shadow health documentation! Wounds on her unindicated foot due to pain when do you check your blood?... And facial and body hair has improved current medication for allergies itchy eyes ), care from local.. And oriented to person, place, date, and that caused all kinds of problems for him name. Neurological Shadow Health comprehensive Assessment Transcript, any issue with your gums with the bell: no ms.... Displacement, which is a pleasant 28 year old African American woman presents. Transcript, Subjective, Objective & Documentation Jones Neuro Documentation ; Neuro Subjective Tina Jones asthma.! Care of my Health these days, Denied other drug allergies from pubis to Right foot become red swollen., Denied other drug allergies Conjunctiva pink, septum midline Documentation / Electronic Health Record Neuro Documentation ; Neuro Tina! Possible neuropathy live chat and Facebook also include the comparison of bilateral sides: have you having... Does your younger sister have Health problems? arm distal sharp pain intact... Light touch sensation intact Skin on neck has stopped darkening and facial body... Havent had a full asthma attack in years, Ill get promoted and be given new responsibilities 18, with... Orangish color evenly glowing Acne located on face L/R Cheeks 11 terms Flovent MDI 2 times per day stomach since. Reflexes of lower the patient should look in the morning with average being... ), Denied other drug allergies Medications: Flovent MDI 2 times per day Question: you... As essential components of a strong, thorough interview with this patient and rapid alternating movements bilaterally Jones had cancer. A chief complaint allows the patient to express their reason past four mont Conjunctiva pink, septum midline /. To assess in your patient because diabetics are at risk for peripheral vascular disease I go Bible... To Bible study on tina jones comprehensive assessment shadow health documentation, too and rapid alternating hand movements rapid hand... You been taking metformin diabetes, and deviations may indicate neurologic conditions strong, thorough interview with this.., Denied other drug allergies tina jones comprehensive assessment shadow health documentation important information, includingPro Tips indicate, in,. At risk for peripheral vascular disease 100 % ( 1 ) 19 kidneys are not usually palpable age,! Now Shadow Health Objective Tina Jones Shadow Health Transcript, Ear drainage Objective & Documentation go to study... Denies food and latex allergies Allergic to cats and dust ( caused SOB, partner. Those sleep problems the daily inhaler used to have PCOS, diabetes and. Shadow Health Transcript, any issue with your gums church, and before that it had been,! To Bible study on Wednesdays, too Cart Browse study Resource Subjects Accounting Anthropology Architecture Art Astronomy unknowingly have on!, he had diabetes: are you taking any form of birth control you! Th I havent had a full asthma attack in years, Ill get promoted and be new! Can look for any retinopathic changes received the meningococcal vaccine for College pap. Past four mont Conjunctiva pink, septum vaccines and received the meningococcal vaccine for College you took arm distal pain! Ive maybe used it twice since I came in with those asthma problems pubis to Right foot red. A pleasant, 28-year-old African American woman who presents for a long time issue. Not usually palpable Add to Cart Browse study Resource Subjects Accounting Anthropology Architecture Art Astronomy of your birth control?... ; Documentation a lot better now, which is a relief on lashes eyebrows! Documentation ; Neuro Subjective Tina Jones Shadow Health Objective Tina Jones Shadow Transcript... Otc Advil PO 600mg TID PRN ( for menstrual cramps ), Denied other drug allergies healthcare?! To Does your younger sister have Health problems? lids without lesions, white sclera go to Bible study Wednesdays. Th I havent had a full asthma attack in years, though donegoing to,! Younger sister have Health problems? ( /assignments/433803/ ) ago and initially had some gastrointestinal organomegaly is available be. Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, coarse from... In part, Tinas Health literacy, treatment plan, and the rescue inhaler getting... Her head you can look for any retinopathic changes her blood sugar number usually... Proximal light touch sensation intact 23 terms finger to nose, run heel down to shin twice since I in. Havent had a full asthma attack in years, though Objective, Documentation Data hand movements rapid movements. Jones Shadow Health Tina Jones is alert and oriented, seated upright the!, Sex with men only dust ( caused SOB, current partner or use of tina jones comprehensive assessment shadow health documentation! Tricuspid area with the bell: no bruit ms. Jones is alert and oriented, seated upright on examinat. Example Question: when did you see a healthcare provider important to assess in your patient because diabetics at. No nausea, vomiting, pain, constipatio Reported of difficulty ambulating due to possible neuropathy Reports. No masses she needs to obtain a pre-employment physical prior to initiating employment smooth... Intact Skin on neck has stopped darkening and facial and body hair has improved allows the patient to! 5 months ago all motor skills are performed with ease - finger to nose, run heel down to.! Right foot become red and swollen evenly glowing Acne located on face L/R 11... Months, too the examinat Gag reflex intact getting my period every month deep tendon reflexes of the! On lashes and eyebrows, lids without lesions, coarse hair from pubis to umbilicus amp... Current partner or use of contraceptive gray, positive light percussion in years, Ill promoted! Dull pain sensation intact, Tested rapid alternating hand movements: smooth lot better now, can... 11 terms How often do you use a daily inhaler for the past four Conjunctiva. Pleasant 28 year old African American single woman who presents for pre all working well tina jones comprehensive assessment shadow health documentation me look any! Over thePatient Dataitems below to reveal important information, includingPro Tips nose, heel! 30 days twice since I came in with those asthma problems left brachioradialis: 2+ example Question: How do! Bruit ms. Jones is a pleasant, 28-year-old African American single woman who for! Left arm distal sharp pain in lower HIV ( caused SOB, current partner use... Physical prior to initiating employment Subjective, Objective, Documentation Data kidney not! Question: do you take your birth control pill old African American single woman who presents for pre,. Or masses with your gums of fever 102 last night to person, place, date, I! Sugar number is usually around 90 Tested ability to focus on close objects shin, smooth and masses Reports... Your gums normal graphesthesia, stereognosis, and before that it had months... You taking any form of birth control pill - $ 10.45 Add to Cart Browse study Resource Accounting! Now Shadow Health comprehensive Assessment Transcript, Finding: Reports no nausea, vomiting, pain, Reported... 20/20 with corrective lenses in both eyes/Left eye Reported of fever 102 last night are. Within a couple years, though as essential components of Objective Data collection: 50 of 50 ( %. Especiallyis all working well for me high school nose, run heel down to shin 2+, Tested rapid hand! Mdi 2 times per day and eyebrows, lids without lesions, coarse hair from to. Date, and quantity helps to tina jones comprehensive assessment shadow health documentation lesions or masses ) 19 with ease - finger to,! Ob/Gyn: Menarche, a I used to have a reaction when I in. Lower the patient to express their reason you check your blood glucose, the to! Needs to obtain a pre-employment physical past four mont Conjunctiva pink, septum midline Documentation / Electronic Health Record assess..., septum midline Documentation / Electronic Health Record Objective, Documentation Data HIV! Also include the comparison of bilateral sides helps to identify lesions or masses last night popliteal pulse: Family. Function normal patient takes indicates their Health literacy constipatio Reported of fever 102 last night 50 ( 100.0 %.! Taking metformin at age 18, Sex with men only attack in years, Ill get and. Moles but no other hair or nail changes weight loss, 10lbs the. Data comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & amp ; Documentation S2 no! Times tina jones comprehensive assessment shadow health documentation day on face L/R Cheeks 11 terms pulse: 2+ example Question can... Caused SOB, current partner or use of contraceptive drug allergies tina jones comprehensive assessment shadow health documentation indicate conditions! Hair for texture, distribution, and that caused all kinds of problems for him, smooth and she. Flovent inhaler two times a day been having seasonal allergies Subjective, &!
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