Shadow Health Respiratory Tina Jones Documentation

Nursing students in advanced health assessment courses gain essential practice documenting acute asthma exacerbations when they review the Shadow Health respiratory provider notes for Tina Jones and compare their entries on subjective breathing difficulties with the detailed model documentation for the acute asthma episode.

Documentation / Electronic Health Record

Document: Provider Notes

Subjective

Ms. Tina Jones is a 28 year old African American female who reports to the clinic with complaints of “having breathing problems” with decreased effectiveness from her inhaler. Faculty often remind learners that capturing the patient’s own words about symptom onset strengthens the clinical narrative and supports differential diagnosis. She states that it’s been “hard to take in air”, her chest feels tight, she’s been wheezing and has a new, frequent, nonproductive cough. These symptoms started two days ago, worsening at night when she’s lying down or when she over exerts herself.

She states she changes her bedding and dust weekly. Typically cats or dust triggers her asthma reaction. She states her symptoms began while visiting her cousin who has cats. She only visits her a few times a year. Recent analyses of similar virtual cases note that environmental triggers remain central to patient histories even as inhaler formulations evolve under current guidelines.

Her most recent experience of shortness of breath was this morning before arrival at the clinic. Currently she states that her “breathing feels okay” but during her asthma attacks she would rate the severity at a 7 or 8 out of 10 and with the attack lasting about five minutes total. She uses her albuterol inhaler to treat symptoms, however lately the inhaler hasn’t been as effective at treating the symptoms as it has previously. She has not been hospitalized for asthma since she was a child.

She was diagnosed with asthma at age 2. She treats her asthma with an inhaler only, along with attempting to stay away from cats. She doesn’t keep an asthma diary or use spirometry, peak flow or nebulizer. She denies use of tobacco or alcohol. She hasn’t used marijuanna since she was 21 years old. Does not see a specialist for asthma.

Review of Systems General: Not getting adequate sleep due to asthma symptoms resulting in low energey levels, denies fever, chills, night sweats Nose: Denies congestion, sneezing, runny nose, or environmental allergies besides dust G.I.: No changes in appetite, no N/V, no complaints of abdominal pain Respiratory: Complaints of new onset SOB with wheezing and nonproductive cough, denies pneumonia, bronchitis, emphysema, TB. History of asthma since childhood, no recent hospitalization for asthma.

HPI (Model Documentation)

Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of shortness of breath and wheezing following a near asthma attack that she had two days ago. Instructors observe that the model version consistently links exposure details to symptom timing, which helps students align their own notes more closely with expected clinical standards. She reports that she was at her cousin’s house and was exposed to cats which triggered her asthma symptoms. At the time of the incident she notes that her wheezes were a 6/10 severity and her shortness of breath was a 7-8/10 severity and lasted five minutes. She did not experience any chest pain or allergic symptoms. At that time she used her albuterol inhaler and her symptoms decreased although they did not completely resolve.

Since that incident she notes that she has had 10 episodes of wheezing and has shortness of breath approximately every four hours. Her last episode of shortness of breath was this morning before coming to clinic. She notes that her current symptoms seem to be worsened by lying flat and movement and are accompanied by a non-productive cough. She awakens with night-time shortness of breath twice per night. She complains that her current symptoms are beginning to interfere with her daily activities and she is concerned that her albuterol inhaler seems to be less effective than previous. Currently she states that her breathing is normal.

Diagnosed with asthma at age 2.5 years. She has no recent use of spirometry, does not use a peak flow, does not record attacks, and does not have a home nebulizer or vaporizer. She has been hospitalized five times for asthma, last at age 16. She has never been intubated for her asthma. She does not have a current pulmonologist or allergist. Social History: She is not aware of any environmental exposures or irritants at her job or home. She changes her sheets weekly and denies dust/mildew at her home. She uses a hypoallergenic pillow cover and her mattress is one year old. She denies current use of tobacco, alcohol, and illicit drugs. She did smoke marijuana for 5 or 6 years, her last use was at age 21 years. She does not exercise.

Review of Systems: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. • Nose/Sinuses: Denies rhinorrhea with this episode. Denies stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure. • Gastrointestinal: No changes in appetite, no nausea, no vomiting, no symptoms of GERD or abdominal pain • Respiratory: Complains of shortness of breath and cough as above. Denies sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization was age 16, last chest XR was age 16.

Objective

Ms. Tina Jones is an 28 year old African American female. She is alert and oriented times 4 and is dressed appropriately for the setting. She is currently not under any distress. Chest expansion is symmetric bilaterally with respirations, Chest resonant to percussion with no dullness, normal fremitus, bilateral wheezes heard in posterior lower lobes. Bilateral muffled “99” ascultated in lower posterial lobes. Incentive spirometer results: FVC 3.91 L, FEV1/FVC ratio 80.56%. SpO2: 97%.

General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented and sitting upright on exam table. She maintains eye contact. Updated asthma management resources from recent years continue to stress the value of noting vital signs and lung sounds precisely so that subsequent providers can track changes in real time.

Sample Provider Notes Example

Ms. Tina Jones reports shortness of breath and wheezing that began two days ago after exposure to cats at her cousin’s home. She rates the episodes at 7 to 8 out of 10 and notes that her albuterol inhaler provides only partial relief lately. Objective examination shows bilateral wheezes in the posterior lower lobes with symmetric chest expansion and SpO2 of 97 percent on room air. Incentive spirometry yields an FEV1/FVC ratio of 80.56 percent, consistent with mild obstruction during the current episode. The assessment supports an acute asthma exacerbation triggered by allergen exposure. Plan includes reinforcement of proper inhaler technique and follow-up evaluation within one week. According to Cloutier et al. (2020; https://doi.org/10.1016/j.jaci.2020.10.003), current guidelines recommend reviewing reliever effectiveness when symptoms persist despite standard therapy. Overall the documentation links subjective history directly to measurable findings and guides next steps effectively.

Follow-up Considerations for Documentation Practice

Accurate provider notes in virtual simulations prepare future nurses to handle real-world respiratory cases where subtle details affect treatment decisions. Simulation research demonstrates measurable gains in clinical judgment when learners compare their documentation against expert models before submitting final entries. Educators often find that repeated practice with cases like Tina Jones helps reduce common omissions such as incomplete trigger histories or overlooked social factors. Students may also benefit from cross-referencing their notes with the latest asthma management recommendations to ensure alignment with evidence-based standards. Such focused review builds confidence and supports safer transitions into clinical rotations.

References

Cloutier, M.M. et al. (2020) ‘2020 focused updates to the asthma management guidelines: A report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group’, The Journal of Allergy and Clinical Immunology, 146(6), pp. 1217–1270. Available at: https://doi.org/10.1016/j.jaci.2020.10.003.

Kang, K.A., Kim, S. and Lee, Y. (2020) ‘Comparison of the learning effects of virtual reality simulation and high-fidelity simulation for nursing students in caring for children with asthma’, International Journal of Environmental Research and Public Health, 17(22), p. 8417. Available at: https://doi.org/10.3390/ijerph17228417.

Marko, M. et al. (2025) ‘Effective inhaler technique education is achievable’, Frontiers in Pharmacology, 16, p. 1538283. Available at: https://doi.org/10.3389/fphar.2025.1538283.

Global Initiative for Asthma (2024) Global strategy for asthma management and prevention. Available at: https://ginasthma.org/wp-content/uploads/2024/05/GINA-2024-Strategy-Report-24_05_22_WMS.pdf.

• Shadow Health Tina Jones respiratory documentation provider notes example student model comparison
• Tina Jones Respiratory Assessment
• Shadow Health Respiratory Tina Jones Documentation Guide
• Accurate Provider Notes for Tina Jones Asthma Exacerbation in Shadow Health Simulation
• When Students Compare Their Respiratory Documentation Against Model Entries for Tina Jones
• Complete your documentation of the Shadow Health respiratory assessment for Tina Jones with clear provider notes that cover subjective symptoms and objective lung findings in 800 words or less. (word count)
• Submit accurate 2-page provider notes for the Tina Jones respiratory case in Shadow Health that match model documentation standards for asthma triggers and exam results. (pages length)
• Document subjective and objective data for Tina Jones respiratory Shadow Health assessment using the provided student and model examples. (short form/summary)

Assignment (Module 4 – Week 4 Discussion Post)

Cardiovascular Assessment and Documentation for Tina Jones in Shadow Health

In the upcoming module learners will perform a focused cardiovascular examination on the same virtual patient and document relevant findings in provider note format. Students prepare a 400-word post that compares their subjective and objective cardiovascular data with the model documentation while addressing any links to her known asthma history. The post must incorporate at least one current guideline reference and discuss how integrated system assessments improve overall clinical reasoning. Instructors evaluate clarity, completeness, and evidence-based connections between respiratory and cardiovascular findings.