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Documentation / Electronic Health Record

Vitals Student DocumentationStudent Documentation Model DModel D

B/P 128/82, HR 78, RR 15, T 37.2C, Pox 99%, Pain 0/10, FVC 1.78, FEV 1.549 N/A

Health History Student Documentation Student Documentation Model D Model D Identifying Data & Reliability 28 year-old AA female, calm/cooperative, good historian.


General Survey Mrs. Jones is a well appearing 28-year-old AA female, A+O x4, NAD VSS, 0/10 pain, last menstral period 2 weeks ago.


Reason for Visit Tina is in for a general physical required for her insurance through new job.


History of Present Illness Patient is here to have a general physical for her new job and insurance requires it. Patient has no real complaints at this time.




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Student DocumentationStudent Documentation Model DModel DMedications Metformin Daily (most likely steroid) Inhaler Albuterol inhaler Zantac Yaz (birth control)


Allergies No known drug allergies Allergic to cats.


Medical History DM2 Asthma GERD PCO2 Palpitations Lower back pain Hypertension Anxiety Sleeplessness irregular menstral cycles


Health Maintenance Eating better, exercising, recent weight loss. Eye exam 3 months ago, new Rx eye glasses GYN visit 4 months ago. Physical 5 months ago. Had denal visit.


Family History Mother has hypertension and hyperlipidemida; Father has hypertension, hyperlipidemia, and diabetes; Paternal grandparents and Maternal grandparents patient is unceratin with health history.


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Student Documentation Student Documentation Model DModel DSocial History Patient follows fairly strict diabetic diet, keeps caffeine intake to 2 diet soda a day, patient is occaisonal drinker and never has more than a few sporadically, patient engages in walking at least 3 to 5 times a weeks for over 30 minutes, and patient is currently seeing new boyfriend, not sexually active yet, and has support system of mom, friends, and siblings and currently lives with mother.


Mental Health History Patient denies any real anxiety or stress at present time, but history of both due to passing of grandparent, but denies ever having depression, and verbalizes appropriate sleep patterns.


Review of Systems – General General: Tina denies fatigue, fever, or chills HEENT: patient denies hearing issues, double vision, sneezing/rhinitis, denies issues with swallowing/eating, denies tenderness to neck and has full ROM. Skin: denies any rashes, itchiness, dry skin, wounds, scars, Respiratory: patient denies SOB, wheezing, asthma excaerbations, cough. Cardiovascular: Tina denis palpitations, chest pain, tightness, discomfort, or edema Gastrointestinal: denies nausea, vomiting, diarrhea, constipation, heartburn, gas Genitourinary: Denies frequency, urgency, polyuria, urine yellow straw-colored, denies heavy period flow, irregular menses, or cramping. Neurological: denies any numbness, tingling, dizzyness, headaches, or change in bowel/bladder control. Musculoskeletal: denies weakness, pain, verbalizes steady gait, Hematologic/Endocrin: denies any easy bruising, blood clots, denies issues iwth diabetes (in good control), denies heat/cold intolerance Psychiatric: denies depression, anxeity, mood swings, stress.


HEENT Student Documentation Student Documentation Model D Model D

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Student DocumentationStudent Documentation Model DModel DSubjective Patient verbalizes use of glasses, no problems with hearing, swallowing, mourht, or neck problems.


Objective Head: head supples, no masses noted, no tenderness Eyes: no limitations to vision, extraoccular movemnts intact, sclera white and conjunctiva pink/moist, field of vision intact. Ears: hearing normal, passed whisper test, all structures intact and WNL Nose: membranes moist/pink, no inflammation, drainage noted. Mouth: teeth intact, gums pink/intact, toungue pink without defect Neck: no tenderness, no masses palpaable, full ROM, thyroid normal size


Respiratory Student DocumentationStudent Documentation Model DModel D Subjective No complaints of SOB, wheezing, cough, pain upon inspiration/expiration, uses inhalers as prescribed.


Objective Inspection of chest anteriorly and posteriorly WNL, no tactile fremitus throughout, chest expansion equal/symmetrical and without difficulty, all areas posteriorly resonant, and anteriorly as well, lung sounds clear throughout without any crackles, or wheezes, or rubs noted.




Student Documentation Student Documentation Model D Model D

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Student Documentation Student Documentation Model D Model D Subjective Patient denies palpitations, chest pain.


Objective S1, S2, no murmurs, all pulses 2+ throughout with no bruits/thrills, PMI nondisplaced with no heaves or lifts, capillary refill in both hands and feet <2 sec/brisk.


Abdominal Student DocumentationStudent Documentation Model DModel D Subjective No complaints of reflux, gas, pain, diarrhea, constipation, bleeding in stools, daily bowel movements with no difficulties.


Objective Bowel sound normoactive all quadrants, no masses palpable, soft and non-tender, liver palpable 1cm below right costal margin, spleen not palpable, kidneys not palpable and no masses, absence of CVA tenderness,


Musculoskeletal Student DocumentationStudent Documentation Model DModel D Subjective No complaints of weakness, pain, or difficulty walking, or picking up, or bending/twisting.


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Student DocumentationStudent Documentation Model DModel DObjective All extremities,neck, shoulder, hip, back 5/5 strength, ROM WNL for all extremites, neck, all areas adduction, abduction, inversion, eversion, extension, flexion, bending, supination, pronation, normal, spine midline,


Neurological Student DocumentationStudent Documentation Model DModel D Subjective Patient denies dizzyness, headaches, numbness/tingling, sharp/dull sensation normal throughout.


Objective Heel moving to shin intact, able to touch ringer to nose without difficulty, alert and oriented times 4, memory intact, gross and fine motor movement intact, sharp/dull/soft sensation intact throughout, some sensation loss to left foot near pad/toes, all reflexes 2+, sterognosis and graphesthesia are intact.


Skin, Hair & Nails Student DocumentationStudent Documentation Model DModel D Subjective Patient has no complaints of rashes, itching, dry skin, wounds, scars.


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Student DocumentationStudent Documentation Model DModel DObjective No obvious wounds, scars, rashes, discoloration, skin warm.dry, normal for race, nails have no ridges or abnormalities, hair is thick, full, no issues.

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