See attachments
Name: Tina Jones
Section:
Week 4
Shadow Health Digital Clinical Experience Health History Documentation
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC):
History of Present Illness (HPI):
Medications:
Allergies:
Past Medical History (PMH):
Past Surgical History (PSH):
Sexual/Reproductive History:
Personal/Social History:
Immunization History:
Health Maintenance:
Significant Family History (Include history of parents, maternal/paternal Grandparents, siblings, and children):
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History). Remember that the information you include in this section is based on what the patient tells you. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.
General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Psychiatric:
Neurological:
Skin:
Hematologic:
Endocrine:
Instructions
Complete your documentation using the documentation template
Included the Information in different attachment and template
VS: BP – 142/82 HR -86 RR-19 SPO2 99% – oral temperature 101.F , wt 90 kg BMI 31
© 2021 Walden University Page 1 of 1
Name: Tina Jones
Section:
Week 4
Shadow Health Digital Clinical Experience Health History Documentation
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC):
History of Present Illness (HPI):
Medications:
Allergies:
Past Medical History (PMH):
Past Surgical History (PSH):
Sexual/Reproductive History:
Personal/Social History:
Immunization History:
Health Maintenance:
Significant Family History (Include history of parents, maternal/paternal Grandparents, siblings, and children):
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History). Remember that the information you include in this section is based on what the patient tells you. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.
General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Psychiatric:
Neurological:
Skin:
Hematologic:
Endocrine:
© 2021 Walden University Page 1 of 1
DCE Provider Notes – Tina Jones Health History
Identifying Data
Ms. Jones is a pleasant 28-year-old, single, African American, female. She presents to the office
today for a physical examination and with a chief complaint of right foot pain after a recent
injury. She is the primary source of history obtained in addition to the use of her available
medical record. She is able to maintain good eye contact and clear speech throughout the
interview process, as she provides all information freely.
General Survey
Ms. Jones is alert and oriented, with relaxed posture during the assessment process. Her mood
appears to be stable, and she does not appear to be in any distress. Her immediate and remote
memory appear to be intact. She appears to have good hygiene and is dressed appropriately for
the current weather and occasion.
Chief Complaint: “I got this scrape on my foot a while ago, and I thought it would heal up on
its own, but now it’s looking pretty nasty. And the pain is killing me!”
History of Present Illness
Ms. Jones presents today for a physical examination and with report of a scrape to the ball of her
right foot. She reports that she obtained the scrape 1 week ago when she tripped going down the
stairs and scraped her bare foot on the edge of the step. She reports bleeding at the time of injury,
and shares that she has been washing the wound with soap and water twice daily (morning and
night), and that she has been using Neosporin prior to keeping it bandaged. She added that she
sometimes uses peroxide and then rinses the area when it is irritated. She reports that the scrape
is not healing on its own, “is not looking well”, and is causing her pain. Her current pain level is
a 7/10, and she describes the pain as “throbbing” and “sharp” when weight is applied. She reports
that her entire right foot feels some pain, but the pain is the worst at the center/ball of her foot.
She added that the pain also radiates up her ankle. She has not been able to walk due to this pain.
She has been taking Tramadol 100 mg three times daily for pain, but feels that this only
alleviates the pain for a few hours. She reports that the area has been red and swollen with noted
pus, heat, and increased pain over the last 2 days ago. She denies noted odor.
Medications
Tramadol 50 mg tablets. Taking 2 tablets (100 mg Total) 3 times daily for pain.
Proventil Inhaler 90 mg 2- 3 puffs 2-3 times per week for asthma symptoms.
Advil 200 mg tablets. Taking 3 tablets (600 mg Total) up to 3 times daily for menstrual
cramps.
o Patient self-discontinued Metformin and birth control pill use 3 years ago.
o She denies use of any other vitamins, supplements, or additional OTC medications.
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