Dermatology school age sick visit shadow health Noah Caputo
Recording information in the computer system about the visit to the doctor.
Table of Contents
Forms to track Noah’s health:
– My notes as the provider
– Notes about tests done
– Records of Noah’s body measurements
– Details of Noah’s current health visit
Details recorded in the computer system:
– My notes as the provider
– Notes made by students shadowing the doctor
What Noah’s uncle tells us:
Noah Caputo is a boy who is 7 years old. He came to the clinic with his uncle because his feet and legs itch. Noah says the itching started last weekend. He says the rash is red and bumpy. Noah hasn’t used any medicine on it, but his uncle put a cold cloth on his legs, and it helped. Noah’s uncle also gave him a medicine called children’s diphenhydramine, which made Noah feel better. Noah isn’t taking any medicine regularly, and he’s not allergic to any medicine. He doesn’t have any health problems. Noah’s uncle isn’t sure if Noah got all his shots. Noah’s family doesn’t have any history of skin problems. Noah doesn’t have a fever, isn’t tired, and doesn’t feel sick. He’s not having any pain or feeling cold.
Dermatology school age sick visit shadow health Noah Caputo
Documentation / Electronic Health Record
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 |
Documentation / Electronic Health Record
My Provider Notes
| Student Documentation | Model Documentation |
|---|---|
SubjectiveNoah 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 |
