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Tanner Bailey Documentation Electronic Health Record
Health Assessment Of Individuals Across The Lifespan (NUR 3065L)
University of North Florida
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Documentation / Electronic Health Record
Documentation: Provider Notes
Documentation: Provider Notes
Student Documentation Model Documentation
Subjective Patient states he picked up a heavy box at work approximately 13 weeks ago, states he did not use proper body mechanics. States the pain "has been killing me" and states he needs to be on opioids. He states his pain is sharp and burning and comes and goes throughout the day and "at it's worst" is 7 out of 10. He states he has been sedentary and walking makes the pain worse, as well as bending and lifting. He states he sits and lies around and shifts to make the pain better. He admits to taking a friend's prescription medication: a combination of hydrocodone 5 mg and acetaminophen 325 mg. He also states he drinks 3 glasses of whisky a day to keep the pain down. He was advised to stop this medication and drinking alcohol while taking prescription medication patient states his coworker took him to the emergency room immediately after the injury. He states "they couldn't figure out what was wrong with my back" and also states that he was told he needed physical therapy and to take ibuprofen. The patient states he is a transgender male taking testosterone injections 100 mg once weekly in the deltoid.
CC: “My back is killing me” HPI: Tanne old female to male (FTM) transgender ambulatory to clinic today with concerns reports low back pain that is described tingling that is resulting from a work inj a heavy box thirteen weeks ago. Pain ons after the injury. He reports that he was hospital immediately after the injury for e evaluation did not provide any additiona injury. He was advised at the hospital t and was prescribed ibuprofen. Mr. Bai pain and the pain is intermittent throughout that walking, bending, or lifting aggrava at-home physical therapy. Due to this pa continue physical therapy. He reports pa symptoms with sitting, lying down, res hydrocodone medication and alcohol u ibuprofen 13 weeks ago, but discontinue to ineffectiveness of the medication. H alcoholic drinks daily in order to incre effects of alcohol, but discontinued thi safely use his girlfriend’s hydrocodone has been taking the hydrocodone twice this morning. He is now requesting a pre Allergies: No allergies to medications, l environment Medications: Testosteron intramuscular once weekly for hormone affirmation therapy Past Medical History: History: Reports maternal depression a History: Works as a theatre director- re income • Reports female to male trans reports wearing chest binder to affirm m
This study source was downloaded by 100000835600516 from CourseHero on 05-21-2022 06:49:44 GMT -05:
coursehero/file/100086908/Tanner-Bailey-Documentation-Electronic-Health-Recorddocx/
Student Documentation Model Documentation
Reports decreased alcohol use this wee consume opiates. • Denies illicit substa nicotine use. • Reports having a girlfri sexual activity. Health Promotion/Imm childhood vaccines. Reports receiving i months ago. Review of Systems: • Cons chills, sweats, affirms weight loss • Int swelling • Neurological: Denies numbne bowel/bladder incontinence, affirms ti Musculoskeletal: Affirms low back pa bending or lifting
Objective Patient is a transgender male in pain, facial grimacing and reduced mobility noted. States pain 7 out of 10. Blood pressure: 110/72 heart rate: 80 SpO2: 98% temperature: 36 degrees celsius
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This study source was downloaded by 100000835600516 from CourseHero on 05-21-2022 06:49:44 GMT -05:
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Tanner Bailey Documentation Electronic Health Record
Course: Health Assessment Of Individuals Across The Lifespan (NUR 3065L)
University: University of North Florida
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