See attached 

Name:

Section:

Week 7

Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.

History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (i.e. 34-year-old AA male). You must include the 7 attributes of each principal symptom:

1. Location

2. Quality

3. Quantity or severity

4. Timing, including onset, duration, and frequency

5. Setting in which it occurs

6. Factors that have aggravated or relieved the symptom

7. Associated manifestations

Medications: Include over the counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.

Allergies: Include specific reactions to medications, foods, insects, and environmental factors.

Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors.

Past Surgical History (PSH): Include dates, indications, and types of operations.

Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, and sexual function.

Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.

Immunization History: Include last Tdp, Flu, pneumonia, etc.

Significant Family History: Include history of parents, 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. You will only need to cover systems pertinent to your CC, HPI (N/A, UNKNOWN is not acceptable, make up the information if you need to). 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.

Cardiovascular/Peripheral Vascular:

Respiratory:

Gastrointestinal:

3/25/20, 8:31 PMFocused Exam: Chest Pain | Completed | Shadow Health

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Focused Exam: Chest Pain Results | Completed
Advanced Health Assessment – January 2020, nur634

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Documentation / Electronic Health Record

Document: Provider Notes

Student Documentation Model Documentation

Subjective

Mr. Foster is a pleasant 58 years old caucasian man who presented
to the clinic with chief complaints of intermittent chest pain that has
been going on for the past month. There is no evidence of acute
distress at this time and he currently denies chest pain. He states
that his chest pain occured at least three times this month. He states
“I feel it mostly in the middle of my chest. over my heart.” He states
that pain severity at its worst is 5/10, non-radiating, and usually goes
after a couple of minutes. He describes the pain as “mostly feels
tight and uncomfortable right in the middle of the chest.” He further
states “the pain seems to start when I’m doing something physical
and subsides a little bit with rest.” He denies taking any medication
to relieve his chest pain. He reports history of hypertension and
hyperlipidemia and takes Atorvastatin 20mg daily and fish oil for
cholesterol and metoprolol 100mg daily for his hypertension. He
reports that he has not been checking his blood pressure at home
and only gets it checked during clinic visits. He states that his last
physical was about three months ago. Reports ocassional alcohol
consumption. Denies smoking and substance abuse. He denies
shortness of breath, fever or chills and any abdominal dsicomfort. He
denies history of blood clot and bleeding. He states that his mom
died of heart attack.

Pt. reports: “I have been having some troubling chest pain in my
chest now and then for the past month.” Experiencing periodic chest
pain with exertion such as yard work, as well as with overeating.
Points to midsternum as location. Describes pain as “tight and
uncomfortable” upon movement or exertion. Mentioned an episode
upon going up the stairs to bed. Most recent episode was three days
ago after eating a large restaurant dinner. Denies radiation. Pain lasts
for “a few” minutes and goes away when he rests. States “It has
never gotten ‘really bad'” so he didn’t think it was an emergency,

Subjective Documentation in Provider Notes
Subjective narrative documentation in Provider Notes is detailed and organized and includes:
Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS)
ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each system as follows:
General: Head: EENT: etc.

You should list these in bullet format and document the systems in order from head to toe.—

Objective Documentation in Provider Notes – this is to be completed in Shadow Health

Physical exam: Document in a systematic order starting from head-to-toe, include what you see, hear, and feel when doing your physical exam using medical terminology/jargon. Document all normal and abnormal exam findings. Do not use “WNL” or “normal”.
You only need to examine the systems that are pertinent to the CC, HPI, and History.

Diagnostic result – Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned

Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1).–