Name: Tina Jones
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):
Past Medical History (PMH):
Past Surgical History (PSH):
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.
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
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