Tina Jones Gastrointestinal Documentation! RATED A+, Assignments of Nursing

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Student Documentation Model Documentation Subjective Ms. Jones is a pleasant 28 y/o African American woman presenting with complaints of upper stomach pain after eating x1 month. She states the pain is daily after every meal but 3-4 times a week it is worse. She rates the pain 5/10. She describes the pain as "kind of like heartburn" but it is sometimes shaper. She says eating makes it worse. She has noticed increased burping following meals. She said that antacids and time make it better. She is taking the antacids "every few days" which provide some relief. She denies any changes to her diet but notes that she has been eating less to avoid the pain and she has increased her water intake recently. Breakfast is usually a muffin or pumpkin bread, lunch is a sandwich and chips, dinner is a homemade meal and vegetables, and snacks consist of French fries or pretzels. She denies coffee intake but reports drinking about 4 diet cokes per day. She denies tobacco and illicit drug use. She drinks occasionally. She does not exercise. Denies any recent changes in weight. Denies fever, chills, night sweats, fatigue. Denies a diagnosis of hypertension but states she has been told she has high blood pressure in the past. Denies any heart conditions. Denies any cough or sore throat. she has a history of asthma which she uses an inhaler for. She was hospitalized for asthma last at age

16. States that her appetite has not changed but she does experience loss of appetite in anticipation of the pain. Denies nausea/vomiting, Bowel movements are normal with no changes. Denies blood in the stool. Reports increased frequency in urination related to increased water intake. Denies blood in the urine. Denies any known problems with the liver or spleen. HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of upper stomach pain after eating. She noticed the pain about a month ago. She states that she experiences pain daily, but notes it to be worse 3-4 times per week. Pain is a 5/10 and is located in her upper stomach. She describes it “kind of like heartburn” but states that it can be sharper. She notes it to increase with consumption of food and specifically fast food and spicy food make pain worse. She does notice that she has increased burping after meals. She states that time generally makes the pain better, but notes that she does treat the pain “every few days” with an over the counter antacid with some relief. Social History: She denies any specific changes in her diet recently, but notes that she has increased her water intake. Breakfast is usually a muffin or pumpkin bread, lunch is a sandwich with chips, dinner is a homemade meal of a meat and vegetable, snacks are French fries or pretzels. She denies coffee intake, but does drink diet cola on a regular basis. She denies use of tobacco and illicit drugs. She drinks alcohol occasionally, last was 2 weeks ago, and was 1 drink. She does not exercise. Review of Systems: General: Denies changes in weight and general fatigue. She denies fevers, chills, and night sweats. • Cardiac: Denies a diagnosis of hypertension, but states that she has been told her blood pressure was high in the past. She denies known history of murmurs, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, or edema. • Respiratory: She denies shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization was age 16, last chest XR was age 16. • Gastrointestinal: States that in general

Tina Jones – Gastrointestinal

Documentation / Electronic Health Record

Document: Provider Notes

Student Documentation Model Documentation foods are causing her symptoms. I would educate her on decreasing dietary fat and to avoid eating 2-3 hours before bed time. I would encourage her to remain upright for at least 30 minutes after each meal. I would refer her to dietary for a consult and to a GI specialist for the upper endoscopy. I will have Tina follow up in the clinic in 2 weeks but I will instruct her to seek immediate medical attention if she has s/s of GI bleed, weight loss, or chest pains. testing for helicobacter pylori, trial of a proton pump inhibitor, or upper endoscopy. • Educate on when to seek emergent care including signs and symptoms of upper and lower gastrointestinal bleed, weight loss, and chest pain. • Return to clinic in two weeks for evaluation and follow up.