Digital Clinical Experience: Focused Exam: Cough

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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. 

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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.–

Levels of Achievement: Excellent 56 (56%) – 60 (60%) DCE score>93 Good 51 (51%) – 55 (55%) DCE Score 86-92 Fair 46 (46%) – 50 (50%) DCE Score 80-85 Poor 0 (0%) – 45 (45%) DCE Score <79 No DCE completed. Feedback:

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.–

Levels of Achievement: Excellent 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). Good 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). Fair 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). Poor 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. Feedback:

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).–

Levels of Achievement: Excellent 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. Good 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. Fair 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. Poor 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. Feedback:

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.

Document: Provider Notes

Objective

Vital signs: B/P 120/76, pulse 100, respiration 28, Temp. 37.2C (99.0F), oxygen saturation 98%, spirometry FVC: 3.91 L FEV1 3.15 L (FEV1/FVC: 80.5%) Increase respiration at 28, mild tachycardia at 100 bpm. Appearance: stable, seated on the examination table calm and able to make full complete sentences. Redness observed in the nostrils. Breathe sounds clear upon auscultation, alert and oriented x3. Head full of hair and clean, neck smooth and jugular vein non-distended.

Assessment

Cough, Fatigue, Sore throat, Rhinitis, Allergies.

Plan

Order lab work for the throat culture to R/O strep. Cough medicine to be given at night. Encourage fluid intake. Educate family about administration of medication. Encourage family members not to smoke in the house. Follow up with your primary physician.

Documentation / Electronic Health Record

Document: Vitals

Document: Provider Notes

Document: Provider Notes

Student Documentation Model Documentation

Subjective

Daniel who preferred to be called “Danny” Rivera is 8 years old male Spanish whose country of origin is Puerto Rico.

Medical History: No surgery, no prior hospitalization, had pneumonia last year and was treated at urgent care clinic.

Allergies: No known allergies.

Chief Complaint: Danny stated, “my abuela brought me here because I’ve been feeling sick” “I have been coughing a lot, and I feel kind of tired”. He is in 3rd grade.

History of present condition: Cough which started about 5 days ago. Patient stated that cough is “gurgle and watery”, and the color of cough is “gross, slimy stuff”. As per patient, he takes cough medicine given by his mom in the morning, and the color of the medicine is purple. He stated that the medicine helps the cough a little and he does not remember what it is called. Patient stated, “most times I sleep for about 8 hours”, and said, “I haven’t been able to sleep much because of my cough”. Patient reported having running nose and does not have seasonal allergy. Nasal Cavity color is erythema, color of the nasal drainage is clear, watery and thin. Reported pain in the right ear and rated it 3 on a scale of 0-10. Denied pain on the left ear. Patient’s father and grandfather smoke around him. Digital Clinical Experience: Focused Exam: Cough

Family History: Mother has type 2 diabetes, HTN, hypercholesterolemia, spinal stenosis, , obesity.

Father: Is a smoker, HTN, hypercholesterolemia, asthma as a child.

Maternal grand-mother: Type diabetes, HTN.

Maternal grand-father: Smoker, eczema

Paternal grand-mother: died in a car accident at age 52 years old.

Paternal grand-father: No known history.

Social history:

School attendance record: Danny has been out of school for two weeks last year due to pneumonia. He lives with his parents and grand-mother. Grand-mother takes care of him while his parents go to work. He speaks English and family use Spanish in conjunction with English.

N/A

Objective

Vital signs: B/P 120/76, pulse 100, respiration 28, Temp. 37.2C (99.0F), oxygen saturation 98%, spirometry FVC: 3.91 L

FEV1 3.15 L (FEV1/FVC: 80.5%). Weight: 90 lbs., Ht. 4′ 2”.

Increase respiration at 28, mild tachycardia at 100 bpm. Appearance: stable, seated on the examination table calm and able to make full complete sentences. Redness observed in the nostrils. Breathe sounds clear upon auscultation, alert and oriented x3. Head full of hair and clean, neck smooth and jugular vein non-distended.

N/A

Assessment

Cough, Fatigue, Sore throat, Rhinitis, Allergies.

N/A

Plan

Order lab work for the throat culture to R/O strep. Cough medicine to be given at night. Encourage fluid intake. educate family about administration of medication. Encourage family member not to smoke in the house.

Follow up with your primary physician.

Name: Danny

Section:

Week 5

Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

Daniel who preferred to be called “Danny” Rivera is 8 years old Spanish male whose country of origin is Puerto Rico.

Chief Complaint (CC): Cou

History of Present Illness (HPI):

Medications:

Allergies:

Past Medical History (PMH):

Past Surgical History (PSH):

Sexual/Reproductive History:

Personal/Social History:

Immunization History:

Significant Family History (Include history of parents, Grandparents, siblings, and children):

Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History). Remember that the information you include in this section is based on what the patient tells you. You will only need to cover systems pertinent to your CC, HPI (N/A, UNKNOWN is not acceptable, make up the information if you need to). To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text. Digital Clinical Experience: Focused Exam: Cough

General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.

HEENT:

Respiratory:

Cardiovascular/Peripheral Vascular:

Psychiatric:

Neurological:

Lymphatics:

OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P. Do not use WNL or normal. You must describe what you see.

Physical Exam:

Vital signs: Include vital signs, ht, wt., temperature, and BMI and pulse oximetry

General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, and affect and reactions to people and things.

HEENT:

Respiratory: Always include this in your PE.

Cardiology: Always include the heart in your PE.

Lymphatics:

Psychiatric:

Diagnostics/Labs (Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses.)

ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. Digital Clinical Experience: Focused Exam: Cough

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