Dermatology school age sick visit shadow health documentation

Documentation / Electronic Health Record

Table of Contents

– Flowsheets
– My Provider Notes
– Diagnostic Notes

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Vitals
Vitals Current Visit
Height 122 cm
Weight 20.8 kg
BMI 14.3
Temp (<38° C) 36.2° C
HR (60-100) 78
RR (12-20) 22
BP 100/68

My Provider Notes
Student Documentation Model Documentation

Subjective

Noah Caputo, a 7-year-old boy, is brought to the clinic by his uncle due to complaints of an itchy rash on his feet and legs. The patient mentions that the rash started feeling itchy last weekend. He denies any pain, bleeding, or pus.

Reason for seeking care: “Rash on lower legs.”
History of Present Illness: Noah Caputo, a 7-year-old male, is accompanied by his uncle, a non-guardian caretaker. The patient has a pruritic rash on his lower legs, which his uncle noticed one day ago. The rash is described as red bumps on both lower legs. There is no exposure to pets at home, but the patient has been around a neighbor’s dog. Scratching and showering worsen the itching. They haven’t tried any topical treatments for the itching. The patient’s uncle applied a cold compress to his legs, which helped relieve the itch. The patient was given children’s diphenhydramine by his uncle, which provided good relief.
Medications: No current medications.
Allergies: No known medication allergies.
Medical History: No current medical issues. No prior hospitalizations or surgeries.
Social History: Noah enjoys school but reports being bullied. He also reports struggling with preparing meals when home alone at night. He lives with his parents and has heard about allegations of stealing at his school.
Health Maintenance: Uncertain if Noah is up to date on immunizations.
Family History: No known family history of skin conditions.
Review of Systems
Constitutional: Denies fever, chills, fatigue, or pain.

Dermatology school age sick visit shadow health documentation

Flowsheets
My Provider Notes
Diagnostic Notes

Vitals

Vitals	Current Visit
Height	122 cm
Weight	20.8 kg
BMI	14.3
Temp (<38° C)	36.2° C
HR (60-100)	78
RR (12-20)	22
BP	100/68

My Provider Notes

Student Documentation	Model Documentation
Subjective Noah Caputo is a 7-year-old male who is brought to the clinic by his uncle with complaints of an itchy rash in his feet and legs. The patient reports that the rash began last weekend when it started feeling itchy. Denies any pain, bleeding or pus dermatology school age sick visit shadow health documentation.	Reason for seeking care: “Rash on lower legs.” History of Present Illness: Noah Caputo is a 7 year old male here today accompanied by his uncle who is a non-guardian caretaker with a pruritic rash on his lower legs that his uncle noticed one day ago. Describes rash as red bumps on both lower legs. Does not have any exposure to pets at home, but has had exposure to a neighbor’s dog. States scratching at the bumps and showering make it itch worse. They have not tried any topical treatments for the itching. His uncle did try putting a cold compress on his legs to help relieve the itch. His uncle did give him children’s diphenhydramine with good relief. Medications: No current medications. Allergies: No known medication allergies. Medical History: No current medical issues. Denies any prior hospitalizations or surgeries. Social History: Noah reports enjoying school and denies getting in trouble at school. However, he does report being bullied. Caretaker reports hearing that Noah has been stealing at his school. Noah lives with his parents. Reports being home alone at night and struggling to prepare meals for himself. Health Maintenance: Caretaker is unsure if Noah is up to date on his immunizations. Family History: No known family history of skin conditions. Review of Systems Constitutional: Denies fever, chills, fatigue, or pain dermatology school age sick visit shadow health documentation Dont wait until the last minute. Provide your requirements and let our native nursing writers deliver your assignments ASAP. Start My Order

Student Documentation

Model Documentation

Subjective

Noah Caputo is a 7-year-old male who is brought to the clinic by his uncle with complaints of an itchy rash in his feet and legs. The patient reports that the rash began last weekend when it started feeling itchy. Denies any pain, bleeding or pus dermatology school age sick visit shadow health documentation.

Reason for seeking care: “Rash on lower legs.” History of Present Illness: Noah Caputo is a 7 year old male here today accompanied by his uncle who is a non-guardian caretaker with a pruritic rash on his lower legs that his uncle noticed one day ago. Describes rash as red bumps on both lower legs. Does not have any exposure to pets at home, but has had exposure to a neighbor’s dog. States scratching at the bumps and showering make it itch worse. They have not tried any topical treatments for the itching. His uncle did try putting a cold compress on his legs to help relieve the itch. His uncle did give him children’s diphenhydramine with good relief. Medications: No current medications. Allergies: No known medication allergies. Medical History: No current medical issues. Denies any prior hospitalizations or surgeries. Social History: Noah reports enjoying school and denies getting in trouble at school. However, he does report being bullied. Caretaker reports hearing that Noah has been stealing at his school. Noah lives with his parents. Reports being home alone at night and struggling to prepare meals for himself. Health Maintenance: Caretaker is unsure if Noah is up to date on his immunizations. Family History: No known family history of skin conditions. Review of Systems Constitutional: Denies fever, chills, fatigue, or pain dermatology school age sick visit shadow health documentation

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Dermatology school age sick visit shadow health documentation