Assignment 2: Digital Clinical Experience: Focused Exam: Cough NURS 6512
Assignment 2: Digital Clinical Experience: Focused Exam: Cough NURS 6512
Assignment 2: Digital Clinical Experience: Focused Exam: Cough NURS 6512
Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation
SUBJECTIVE DATA:
Chief Complaint (CC): “I guess I’m kind of sick. . . I’ve been coughing a lot’
History of Present Illness (HPI): The affected individual Danny Riviera, an eight-year-old boy, visits the medical center because he has been coughing for several days. According to him, the cough is very clear and has a watery quality. His cough is worse at night, preventing him from getting enough rest. As a result, he struggles to concentrate in class and frequently comes home exhausted. It hurts in his right ear. His mother made the decision to use over-the-counter cough medicine, which only provided temporary relief. Danny claims that he has a cold and that he frequently has a runny nose. In addition, he regularly inhales his father’s secondhand smoke. He has also been diagnosed with pneumonia in the last year. He does not, however, have a fever, breathing difficulties, abdominal pain, chest tightness, or chills. He also has no chest tightness.
Medications: The patient acknowledges that they do take their medications at home. In addition to that, he takes a vitamin every day. In addition to that, he takes a medication for coughing that is purple.
Allergies: NKDA
Past Medical History (PMH): Denies asthma diagnosis. Identifies immunizations as being up to date. Previous symptoms include chronic coughing and pneumonia.
Past Surgical History (PSH): None reported.
Sexual/Reproductive History:
Personal/Social History: Identifies himself as a member of a household that also includes his parents and grandparents. avers having a sense of well-being while at home. Describes a park with a playground in the neighborhood. It is reported that the father smokes in the house.
Immunization History: Immunizations are current.
Significant Family History: He is supported by his biological parents as well as both sets of grandparents.
Review of Systems:
General: During the course of the interview, the patient appears exhausted and coughs several times. Additionally, he seems to be steady.
HEENT: The mucus membrane is moist, and the nasal discharge is clear. However, the back of his throat is red and mucus-filled. His eyes are lifeless, and his conjunctiva is a pinkish hue. The right tympanic membrane appears to be inflamed and red. The lymph nodes in the patient’s right cervical region appear enlarged and tender.
Respiratory: Lacks acute distress, has an increased respiratory rate at the age of 28, clear breath sounds on auscultation, and speaks in complete sentences; bronchoscopy is negative. When you percussed his chest wall, you could hear a resonant tone, and his fremitus was normal and bilaterally consistent.
Cardiovascular/Peripheral Vascular:
Psychiatric:
Neurological:
Lymphatics:
OBJECTIVE DATA:
Physical Exam:
Vital signs:
| Blood Pressure | 120/76 |
| O2 Sat | 96% |
| Pulse | 100 |
| Resp. Rate | 28 |
| Temperature | 37.2 c |
General: During the course of the interview, the patient appears exhausted and coughs several times. Additionally, he seems to be steady.
HEENT: The head is atraumatic and has a normocephalic shape. The mucus membrane is wet, and the discharge from the nose is clear. However, the back of his throat is red and clogged with mucus. His eyes are lifeless, and the conjunctiva around them is a pinkish hue. It seems as though the right tympanic membrane is inflamed and red. The lymph nodes in the patient’s right cervical region appear enlarged, and they have a certain degree of tenderness.
Respiratory: Lacks acute distress, has an increased respiratory rate at the age of 28, clear breath sounds on auscultation, and speaks in complete sentences; bronchoscopy is negative. When you percussed his chest wall, you could hear a resonant tone, and his fremitus was normal and bilaterally consistent.
Cardiology: In S1 and S2, there were no murmurs, gallops, or rubs.
Lymphatics: When palpated, the lymph nodes in the right cervical region are tender.
Psychiatric: No mental issues noted.
Diagnostics/Labs (Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses.)
ASSESSMENT:
Based on the findings of the completed physical examination and the observations that were made, the following possible diagnoses can be made.
- Common cold: The patient complains of having a stuffy nose and a sore throat, which are both symptoms of a common cold. This observation was also supported by the findings of a physical examination, which showed that the patient had swollen lymph nodes.
- Streptococcus throat infection: The patient’s complaint of a sore throat suggests that they may have strep throat. On the other hand, symptoms like nausea, vomiting, headaches, and fever did not present themselves at any point.
iii. Rhinitis is another condition that could have been causing the patient’s symptoms, as they included stuffy nose, sore throat, and drainage from the nose. In addition to this, the patient has a history of recurrent ear infections throughout their lifetime.
- Allergies and asthma: The patient does not have a history of allergic reactions. Nevertheless, it is possible that this condition will occur. This condition may have been the cause of the persistent cough. On the other hand, the patient does not exhibit any symptoms of wheezing, chest pain or tightness, or difficulty breathing.
In this DCE Assignment, you will conduct a focused exam related to cough in your DCE using the simulation tool, Shadow Health. You will determine what history should be collected from the patient, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.
| Model Documentation | |
|---|---|
SubjectiveDanny reports cough lasting two to three days. He described the cough as “watery and gurgly.” He reports the cough is worst at night and keeps him awake. He reported general tiredness because of sleep deprivation.He is experiencing mild soreness in his throat. He reports his mother gave him over-the-counter cough medicine, but it gave him temporal relieve from the cough .He reports frequent cold and runny nose, and states that he had frequent ear infections as a child. He reports a history of pneumonia in the past year. He reports normal bowel movements. He denies fever, headache, dizziness, ear pain nosebleed, trouble swallowing, sputum or phlegm, chest pain, trouble breathing and abdominal pain. He denies cough aggravation with activity. | Danny reports a cough lasting two to three days. He describes the cough as “watery and gurgly.” He reports the cough is worse at night and keeps him up. He reports general fatigue due to lack of sleep. He is experiencing mild soreness in his throat. He reports his mother treated his cough symptoms with over-the-counter medicine, but it was only temporarily effective. He reports frequent cold and runny nose, and he states that he had frequent ear infections as a child. He reports a history of pneumonia in the past year. He reports normal bowel movements. He denies fever, headache, dizziness, ear pain, trouble swallowing, nosebleed, phlegm or sputum, chest pain, trouble breathing and abdominal pain. He denies cough aggravation with activity. |
ObjectiveGeneral Survey: Fatigued appearing young boy seated on nursing station bench. Appears stable. HEENT: Mucus membranes are moist, nasal discharge, and boggy turbinate. Fine bumps on the togue. Cobblestoning in the back of throat. Eyes are dull in appearance, pink Conjunctiva. Cardiovascular: Mild tarchycardia. S1, S2, no murmurs, gallops or rubs. Respiratory: Respiratory rate increased, but no acute distress. Able to speak full sentences. Breath sounds clear to auscultation. | • General Survey: Fatigued appearing young boy seated on nursing station bench. Appears stable. • HEENT: Mucus membranes are moist, nasal discharge, and boggy turbinate. Fine bumps on the tongue. Cobblestoning in the back of throat. Eyes are dull in appearance, pink conjunctiva. • Cardiovascular: Mild tachycardia. S1, S2, no murmurs, gallops or rubs. • Respiratory: Respiratory rate increased, but no acute distress. Able to speak in full sentences. Breath sounds clear to auscultation. |
Photo Credit: Getty Images
Assignment 2: Digital Clinical Experience: Focused Exam: Cough NURS 6512
To Prepare
Review this week’s Learning Resources and consider the insights they provide related to ears, nose, and throat.
Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation within the Shadow Health platform. Review the examples also provided.
Review the DCE (Shadow Health) Documentation Template for Focused Exam: Cough found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
Review the Week 5 Focused Exam: Cough Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Focused Exam: Cough Assignment:
Assignment 2: Digital Clinical Experience: Focused Exam: Cough NURS 6512
Complete the following in Shadow Health:
Respiratory Concept Lab (Required)
Episodic/Focused Note for Focused Exam: Cough
HEENT (Recommended but not required)
Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve a total of 80% or better (this includes your DCE and your Documentation Notes), but you must take all attempts by the Week 5 Day 7 deadline.
Click here to ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT: Assignment 2: Digital Clinical Experience: Focused Exam: Cough NURS 6512
Assignment 2: Digital Clinical Experience: Focused Exam: Cough NURS 6512
Submission and Grading Information
By Day 7 of Week 5
Complete your Focused Exam: Cough DCE Assignment in Shadow Health via the Shadow Health link in Blackboard.
Once you complete your Assignment in Shadow Health, you will need to download your lab pass and upload it to the corresponding assignment in Blackboard for your faculty review.
(Note: Please save your lab pass as “LastName_FirstName_AssignmentName”.) You can find instructions for downloading your lab pass here: https://link.shadowhealth.com/download-lab-pass
Once you submit your Documentation Notes to Shadow Health, make sure to copy and paste the same Documentation Notes into your Assignment submission link below.
Download, sign, date, and submit your Student Acknowledgement Form found in the Learning Resources for this week.
Grading Criteria
Assignment 2: Digital Clinical Experience: Focused Exam: Cough NURS 6512
Assignment 2: Digital Clinical Experience: Focused Exam: Cough NURS 6512
To access your rubric:
Week 5 Assignment 2 DCE Rubric
Submit Your Assignment by Day 7 of Week 5
To submit your Lab Pass:
Week 5 Lab Pass
To participate in this Assignment:
Week 5 Documentation Notes for Assignment 2
To Submit your Student Acknowledgement Form:
Submit your Week 5 Assignment 2 DCE Student Acknowledgement Form
What’s Coming Up in Week 6?
Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images
Next week, you will evaluate abnormal findings in the area of the abdomen and the gastrointestinal system. In addition, you will appraise health assessment techniques and diagnoses for the heart, lungs, and peripheral vascular system as you complete your Lab Assignment in assessing the abdomen in a SOAP note format. You will also take your Midterm Exam, which covers the topics in Weeks 1–6. Please review the previous weekly content and resources to help you prepare for your exam. Plan your time accordingly.
Week 6 Required Media
Photo Credit: [fergregory]/[iStock / Getty Images Plus]/Getty Images
Next week, you will need to view several videos and animations in the Seidel’s Guide to Physical Examination as well as other media, as required, prior to completing your Lab Assignment. There are several videos of various lengths. Please plan ahead to ensure you have time to view these media programs to complete your Assignment on time.
Next Week
To go to the next week:
Week 6
Week 6: Assessment of the Abdomen and Gastrointestinal System
On your way home from dinner, you start experiencing sharp pains in your abdomen. You ate seafood—could you have food poisoning? What else might be causing your pain? Appendicitis? Should you head to the emergency room, or should you wait and see how you feel in the morning?
Numerous ailments can affect the GI system and the abdomen. Because the organs are so close, it can be difficult to conduct an accurate assessment. Also, pain in another area of the body can affect the GI system. For example, patients with chronic migraines often report nausea.
This week, you will explore how to assess the abdomen and gastrointestinal system.
Learning Objectives
Students will:
Assignment 2: Digital Clinical Experience: Focused Exam: Cough NURS 6512
Evaluate abnormal abdomen and gastrointestinal findings
Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the abdomen and gastrointestinal system
Identify concepts, theories, and principles related to advanced health assessment
Learning Resources
Required Readings (click to expand/reduce)
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Chapter 6, “Vital Signs and Pain Assessment”
This chapter describes the experience of pain and its causes. The authors also describe the process of pain assessment.
Chapter 18, “Abdomen”
In this chapter, the authors summarize the anatomy and physiology of the abdomen. The authors also explain how to conduct an assessment of the abdomen.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
Chapter 3, “Abdominal Pain”
This chapter outlines how to collect a focused history on abdominal pain. This is followed by what to look for in a physical examination in order to make an accurate diagnosis.
Chapter 10, “Constipation”
The focus of this chapter is on identifying the causes of constipation through taking a focused history, conducting physical examinations, and performing laboratory tests.
Chapter 12, “Diarrhea”
In this chapter, the authors focus on diagnosing the cause of diarrhea. The chapter includes questions to ask patients about the condition, things to look for in a physical exam, and suggested laboratory or diagnostic studies to perform.
Chapter 29, “Rectal Pain, Itching, and Bleeding”
This chapter focuses on how to diagnose rectal bleeding and pain. It includes a table containing possible diagnoses, the accompanying physical signs, and suggested diagnostic studies.
Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.
Credit Line: Advanced practice nursing procedures, 1st Edition by Colyar, M. R. Copyright 2015 by F. A. Davis Company. Reprinted by permission of F. A. Davis Company via the Copyright Clearance Center.
These sections below explain the procedural knowledge needed to perform gastrointestinal procedures.
Chapter 107, “X-Ray Interpretation: Chest (pp. 480–487)
Chapter 115, “X-Ray Interpretation of Abdomen” (pp. 514–520)
Note: Download this Student Checklist and Abdomen Key Points to use during your practice abdominal examination.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Abdomen: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Abdomen: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
Document: Midterm Exam Review (Word document)
Optional Resource
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.
Assignment 2: Digital Clinical Experience: Focused Exam: Cough NURS 6512
Chapter 9, “The Abdomen, Perineum, Anus, and Rectosigmoid” (pp. 445–527)
This chapter explores the health assessment processes for the abdomen, perineum, anus, and rectosigmoid. This chapter also examines the symptoms of many conditions in these areas.
Chapter 10, “The Urinary System” (pp. 528–540)
In this chapter, the authors provide an overview of the physiology of the urinary system. The chapter also lists symptoms and conditions of the urinary system.
Required Media (click to expand/reduce)
Assessment of the Abdomen and Gastrointestinal System – Week 6 (14m)
Online media for Seidel’s Guide to Physical Examination
It is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapter 17 that relate to the assessment of the abdomen and gastrointestinal system. Refer to Week 4 for access instructions on https://evolve.elsevier.com/
Week 5
Cough Documentation Shadow Health Digital Clinical Experience Concentrated Exam
SUBJECTIVE DATA:
Principal Complaint (PC): Abuela brought him in because he has been feeling ill, coughing frequently, and feeling somewhat exhausted.
“History of Present Illness” Danny’s cough has lasted four to five days. The cough is described as ” watery and gurgling.” He is exhausted because his cough is worse at night and keeps him awake. He experiences discomfort in his right ear and in his throat. His mother treated his cough with over-the-counter cough medication that was momentarily beneficial, according to him. He experiences regular colds and nasal discharge. The patient has not been exposed to any sick individuals. Patient denies having allergies
Medications: Pt. rejects daily prescriptions. He takes a daily OTC multivitamin. Today, his mother administered a cough medication that momentarily alleviated his problems.
Allergies:
As a young child, I suffered from recurrent ear infections. The patient’s last reported ear infection occurred when he was 2 years old. His last bout with pneumonia prompted him to miss two weeks of school.
Previous Surgical Experience (PSH): No surgical history
Sexual/Reproductive History: I have never been sexually active.
Personal/Social History: In the third grade Out for two weeks last year due of pneumonia
Live with Mother, Father, grandma, grandmother cares for child while parents are working
Primarily speaks English in the house but sometimes Spanish
Immunization History: Rivera’s immunization record is up to date.
Significant Family History: Mother: type 2 diabetes, high blood pressure, high cholesterol, spinal stenosis, and obesity Father was a smoker with hypertension and hypercholesterolemia. Asthma in childhood
maternal grandmother: type 2 diabetes and high blood pressure The maternal grandfather was a smoker with eczema. 52-year-old maternal grandmother perished in an automobile accident. grandfather paternal: unknown history
Assignment 2: Digital Clinical Experience: Focused Exam: Cough NURS 6512
General: Denies fever, denies chills, denies weigh loss or gain, denies night sweats.
Reports feeling “kind of exhausted.”
The mucous membranes, nasal discharge, and turbinate are wet. There are minute pimples on the tongue. Stones in the back of the throat. The eyes appear dull, with pink conjunctiva.
Cardiovascular: Mild tachycardia. S1, S2, no murmurs, gallops or rubs. The right tympanic membrane is inflamed and red.
Respiratory: Increased respiratory rate, but no acute distress. able to speak in complete sentences Auscultation reveals that breathing is audible. Resonant chest wall upon percussion
Cardiovascular/Peripheral Vascular: Mild tachycardia. S1, S2, no murmuring
No previous history of mental illness
No neurological deficits were observed, and the patient was attentive and oriented to time and location.
Lymphatics: the right cervical lymph node is swollen and painful.
OBJECTIVE DATA: From head-to-toe, detail what you see, hear, and feel when completing your physical\sexam. Unless you are conducting a comprehensive H&P, you only need to investigate the systems that are related to the CC, HPI, and History. Use neither WNL nor normal. You must explain what you observe.
Assignment 2: Digital Clinical Experience: Focused Exam: Cough NURS 6512
Physical Checkup:
Vital signs: Blood Pressure: 120/76; Oxygen Saturation: 96; Pulse Rate: 100; Respiratory Rate: 28; Body Temperature: 37.2; Height: 50 inches; Weight: 68 pounds; Body Mass Index: 19.1
Patient appeared to be in excellent condition and oriented to time.
The sclera is white, and the conjunctiva is pink and wet bilaterally. Rhinorrhea with clear mucus; bilaterally swollen nasal mucosa. The right tympanic membrane is inflamed and erythematous. The right cervical lymph node is swollen and painful to the touch. Oral mucosa is hydrated and pink. Tonsils 2+ characterized by erythema and inflammation. The posterior pharynx is erythematous and pebbled. On the tongue are little bumps.
Respiratory: With respiration, the chest is symmetrical. Enhanced respiration rate audible harsh crackles in the upper airway; bilateral bronchovesicular congestion that is cleared by coughing. Contrary bronchophony. Chest wall that resonates with percussion. Expected fremitus, bilaterally equivalent. Spirometry: FVC = 1.78L FEV1 = 1.549L FEV1/FVC: 87 percent
Mild tachycardia was observed, with no gallops or murmurs. Heart sounds S1 and S2 are present and regular.
Lymphatics: cervical lymph nodes are palpable on the right side, not the left. There are no palpable lymph nodes in the axilla. No lymph nodes are palpable in the supraclavicular area. No tenderness or pain was detected throughout the assessment.
No previous psychiatric diagnosis
Diagnostics/Labs: Chest X-ray to exclude pneumonia; Covid swab to exclude influenza. Covid
ASSESSMENT:
Respiratory tract infection: Common URI symptoms include cough, sore throat, and runny nose; examination of these symptoms is sufficient for diagnosis, especially in the absence of more serious respiratory illness such as coloured phlegm, difficulty breathing, or chest congestion (Thomas & Bomar, 2020).
Differential diagnoses:
Upper respiratory infections frequently affect the pharynx and create discomfort and inflammation there (Thomas & Bomar, 2020). Due to the mild sore throat, redness, and cobblestoneing observed upon examination, this is a plausible differential diagnosis.
Allergic rhinitis: The reports of cough and runny nose with clear sputum and red cobblestoning throat, an abnormal evaluation finding when polygonal cells protrude from mucosal surfaces, may be indicative of allergic rhinitis caused by numerous allergens. (La Mantia & Andaloro, 2017)
Covid: In the current condition of the Covid pandemic, it may be prudent to test for Covid in the presence of modest symptoms to prevent the disease’s spread. While Covid patients report a variety of clinical symptoms, including as cough, runny nose, and sore throat, these symptoms are frequently reported and common even in the absence of lung congestion, fever, or discomfort (Arashiro et al., 2020).
Assignment 2: Digital Clinical Experience: Focused Exam: Cough NURS 6512
References
Arashiro, T., Furukawa, K., & Nakamura, A. (2020). COVID-19 in two cruise ship passengers with moderate upper respiratory symptoms, Japan. Emerging Infectious Diseases, volume 26, number 6, pages 1345–1348. https://doi.org/10.3201/eid2606.200452
La Mantia, I., & Andaloro, C. (2017). The nasopharyngeal mucosa has a cobblestone appearance.
220–220. The Eurasian Journal of Medicine, 49(3).
https://doi.org/10.5152/eurasianjmed.2017.17257
M. Thomas and P. Bomar (2020, October 28). Acute upper respiratory infection. StatPearls\s[Internet]. https://www.ncbi.nlm.nih.gov/books/NBK532961/
Rubric Detail
Select Grid View or List View to change the rubric’s layout.
Name: NURS_6512_Week_5_DCE_Assignment_2_Rubric
Description: To complete the Shadow Health assignments, it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions and the physical assessment areas. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Weeks 1 and 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score.
Grid View
List View
Excellent Good Fair Poor
Student DCE score
(DCE percentages will be calculated automatically by Shadow Health after the assignment is completed.)
Note: DCE Score – Do not round up on the DCE score.
56 (56%) – 60 (60%)
DCE score>93
51 (51%) – 55 (55%)
DCE Score 86-92
46 (46%) – 50 (50%)
DCE Score 80-85
0 (0%) – 45 (45%)
DCE Score <79
No DCE completed.
Subjective Documentation in Provider Notes
Subjective narrative documentation in Provider Notes is detailed and organized and includes:
Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS)
ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each system as follows:
General: Head: EENT: etc.
You should list these in bullet format and document the systems in order from head to toe.
16 (16%) – 20 (20%)
Documentation is detailed and organized with all pertinent information noted in professional language.
Documentation includes all pertinent documentation to include Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).
11 (11%) – 15 (15%)
Documentation with sufficient details, some organization and some pertinent information noted in professional language.
Documentation provides some of the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).
6 (6%) – 10 (10%)
Documentation with inadequate details and/or organization; and inadequate pertinent information noted in professional language.
Limited or/minimum documentation provided to analyze students critical thinking abilities for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).
0 (0%) – 5 (5%)
Documentation lacks any details and/or organization; and does not provide pertinent information noted in professional language.
No information is provided for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).
or
No documentation provided.
Objective Documentation in Provider Notes – this is to be completed in Shadow Health
Physical exam: Document in a systematic order starting from head-to-toe, include what you see, hear, and feel when doing your physical exam using medical terminology/jargon. Document all normal and abnormal exam findings. Do not use “WNL” or “normal”.
You only need to examine the systems that are pertinent to the CC, HPI, and History.
Diagnostic result – Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned
Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1).
16 (16%) – 20 (20%)
Documentation detailed and organized with all abnormal and pertinent normal assessment information described in professional language.
Each system assessed is clearly documented with measurable details of the exam.
11 (11%) – 15 (15%)
Documentation with sufficient details and some organization; some abnormal and some normal assessment information described in mostly professional language.
Each system assessed is somewhat clearly documented with measurable details of the exam.
6 (6%) – 10 (10%)
Documentation with inadequate details and/or organization; inadequate identification of abnormal and pertinent normal assessment information described; inadequate use of professional language.
Each system assessed is minimally or is not clearly documented with measurable details of the exam.
0 (0%) – 5 (5%)
Documentation with no details and/or organization; no identification of abnormal and pertinent normal assessment information described; no use of professional language.
None of the systems are assessed, no documentation of details of the exam.
or
No documentation provided.
Total Points: 100
Name: NURS_6512_Week_5_DCE_Assignment_2_Rubric
Description: To complete the Shadow Health assignments, it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions and the physical assessment areas. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Weeks 1 and 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score.
Assignment 2: Digital Clinical Experience: Focused Exam: Cough NURS 6512
NURS_6512_Week_5_DCE_Assignment_2_Rubric
Description: To complete the Shadow Health assignments, it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions and the physical assessment areas. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Weeks 1 and 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score.
| Excellent | Good | Fair | Poor | |
|---|---|---|---|---|
| Student DCE score (DCE percentages will be calculated automatically by Shadow Health after the assignment is completed.) Note: DCE Score – Do not round up on the DCE score. | Points Range: 56 (56%) – 60 (60%) DCE score>93 | Points Range: 51 (51%) – 55 (55%) DCE Score 86-92 | Points Range: 46 (46%) – 50 (50%) DCE Score 80-85 | Points Range: 0 (0%) – 45 (45%) DCE Score <79 No DCE completed. |
| Subjective Documentation in Provider Notes Subjective narrative documentation in Provider Notes is detailed and organized and includes: Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS) ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each system as follows: You should list these in bullet format and document the systems in order from head to toe. | Points Range: 16 (16%) – 20 (20%) Documentation is detailed and organized with all pertinent information noted in professional language. Documentation includes all pertinent documentation to include Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). | Points Range: 11 (11%) – 15 (15%) Documentation with sufficient details, some organization and some pertinent information noted in professional language. Documentation provides some of the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). | Points Range: 6 (6%) – 10 (10%) Documentation with inadequate details and/or organization; and inadequate pertinent information noted in professional language. Limited or/minimum documentation provided to analyze students critical thinking abilities for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). | Points Range: 0 (0%) – 5 (5%) Documentation lacks any details and/or organization; and does not provide pertinent information noted in professional language. No information is provided for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). or No documentation provided. |
| Objective Documentation in Provider Notes – this is to be completed in Shadow Health Physical exam: Document in a systematic order starting from head-to-toe, include what you see, hear, and feel when doing your physical exam using medical terminology/jargon. Document all normal and abnormal exam findings. Do not use “WNL” or “normal”. You only need to examine the systems that are pertinent to the CC, HPI, and History. Diagnostic result – Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1). | Points Range: 16 (16%) – 20 (20%) Documentation detailed and organized with all abnormal and pertinent normal assessment information described in professional language. Each system assessed is clearly documented with measurable details of the exam. | Points Range: 11 (11%) – 15 (15%) Documentation with sufficient details and some organization; some abnormal and some normal assessment information described in mostly professional language. Each system assessed is somewhat clearly documented with measurable details of the exam. | Points Range: 6 (6%) – 10 (10%) Documentation with inadequate details and/or organization; inadequate identification of abnormal and pertinent normal assessment information described; inadequate use of professional language. Each system assessed is minimally or is not clearly documented with measurable details of the exam. | Points Range: 0 (0%) – 5 (5%) Documentation with no details and/or organization; no identification of abnormal and pertinent normal assessment information described; no use of professional language. None of the systems are assessed, no documentation of details of the exam. or No documentation provided. |
| Total Points: 100 |
|---|