Week 4: Comprehensive Assessment Results | Completed

Week 4: Comprehensive Assessment Results | Completed
Health History
Student Documentation Model Documentation
Identifying Data & Reliability
Ms Tina, 28 year old African American, female, plesant, calm and cooperative. Patient is aware of her health and up to date on her care.
Ms. Jones is a pleasant, 28-year-old African American single wo
who presents for a pre-employment physical. She is the primary
source of the history. Ms. Jones offers information freely and wit
contradiction. Speech is clear and coherent. She maintains eye
contact throughout the interview.
General Survey
Patient looks healthy with no abnormality detected during inspection.
Calm, not anxious, afebrile, anicteric, undertands and responds to
questions appropriately. patient wears glasses for near sightedness.
Ms. Jones is alert and oriented, seated upright on the examinatio
table, and is in no apparent distress. She is well-nourished, welldeveloped, and dressed appropriately with good hygiene.
Reason for Visit
Patient is here for a complete health assessment for pre-employment
physical.
"I came in because I'm required to have a recent physical exam
the health insurance at my new job."

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