Shadow Health Comprehensive Health History and Physical Assessment Assignment - NR 509

Shadow Health Comprehensive Health History and Physical Assessment Assignment – NR 509

NR 509 Week 7: Shadow Health Comprehensive Health History and Physical Assessment Assignment

Pre Brief

In this case study, you will complete the Plan My Exam activity to organize the exam procedures you will use into a sequence that moves smoothly from head to toe by mapping them to the region of the body where you will perform them. After you have planned your exam, you will enter the clinic room and conduct a Comprehensive Assessment by interviewing and examining your Digital Standardized Patient. Shadow Health Comprehensive Health History and Physical Assessment Assignment – NR 509. When collecting information for the comprehensive assessment, be sure to include the following: Shadow Health Comprehensive Health History and Physical Assessment Assignment – NR 509

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Current Illnesses
Past Illnesses
Chronic Illnesses
Past Medical History
Injuries and Treatments
Hospitalizations/Surgeries
Environmental/Food/Drug Allergies
Current Medications/Herbal Remedies/Health Supplements
Past Medications
Habits/Drug and Alcohol Use
Family Medical History
Psychosocial/Cultural/Spiritual History
Sexual History
Obstetric History

As you complete the case study this week, be cognizant of the time that it takes you to conduct the history and physical. In family practice, you are generally allocated a total of 15-minutes for an entire patient visit, which includes taking a history, performing a physical examination, and developing/implementing a treatment plan. You also need to incorporate health promotion into the visit when possible. Be certain to follow a systematic approach during your interview and inquire about each system on the ROS. During the physical exam, be sure to apply the examination skills that you have learned in this course to assess your virtual patient. Shadow Health Comprehensive Health History and Physical Assessment Assignment – NR 509.

Ms. Tina Jones is a pleasant, 29-year-old African American single woman who presents for a pre-employment physical. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview.

Reason for visit: Patient requests a complete health assessment for a pre-employment. Shadow Health Comprehensive Health History and Physical Assessment Assignment – NR 509.

NR 509 Week 7: Shadow Health Comprehensive Health History and Physical Assessment Assignment Rubric

Shadow Health Physical Assessment Rubric

NR 509 Week 7: Shadow Health Comprehensive Health HistoryCriteria

NR 509 Week 7: Shadow Health Comprehensive Health History

Ratings

Pts

Subjective Data, Organization, Communication, and Summary (DCE Score or transcript)

25.0 pts

Above Average- DCE Score greater than or equal to 93; Comprehensive introduction with expectations of exam verbalized; questions worded in a non-judgmental way; professional language exercised; questions well-organized; appropriate closing with summary of findings verbalized to patient.

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21.0 pts

Average- DCE Score greater than or equal to 86-92; Adequate introduction; some questions worded in a non-judgmental way; professional language mostly exercised; questions generally organized; somewhat complete closing.

10.0 pts

Below Average- DCE Score greater than or equal to 80-85; Incomplete introduction; many questions worded in a judgmental way; some professional language exercised; questions somewhat organized; incomplete closing.

0.0 pts

Unsatisfactory- DCE Score less than or equal to 79; Introduction missing; questions worded in a judgmental way; little professional language; questions unorganized; closing missing.

25.0 pts

Objective Data, Physical Examination, Interpretation of Findings, Assessment, and Documentation

20.0 pts

Above Average- Physical assessment documentation includes all relevant body systems; all pertinent normal and abnormal findings identified; documentation reflects professional language; treatment plan includes each of the following components: diagnostics, medication, education, consultation/referral, and follow-up planning.

16.0 pts

Average- Physical assessment documentation lacks sufficient details pertaining to one or two relevant body systems; or identifies ≥ 50% of the pertinent normal and abnormal findings; or documentation lacks professional language; or treatment plan lacks one or two components (diagnostics, medication, education, consultation/referral, or follow-up planning).

8.0 pts

Below Average- Physical assessment documentation lacks sufficient details pertaining to three or more relevant body systems; or identifies < 49% of the pertinent normal and abnormal findings; or documentation includes unprofessional language; or treatment plan lacks three or more components (diagnostics, medication, education, consultation/referral, or follow-up planning).

0.0 pts

Unsatisfactory- No physical assessment documentation or no treatment plan.

20.0 pts

Self-Reflection. Shadow Health Comprehensive Health History and Physical Assessment Assignment – NR 509

5.0 pts

Above Average- Responds to three of the three reflection post questions; and provides analysis of performance; and reflection posts written using professional language; and reflection posts demonstrate insight.

3.0 pts

Average- Responds to two of the three reflection post questions; or provides limited self-analysis of performance; or reflection posts are somewhat unclear related to the assignment and the student’s experience; or reflection posts lack insight.

2.0 pts

Below Average- Responds to one of the three reflection post questions; or does not provide self-analysis of performance; or reflections are not related to the assignment and the student’s experience; or does not provide insight

0.0 pts

Unsatisfactory- No reflection posts for the assignment.

5.0 pts

Total Points: 50 Shadow Health Comprehensive Health History and Physical Assessment Assignment – NR 509