Digital Clinical Experience(DCE) Health History Assessment-SOAP Documentation
Order Instructions
FOCUSED EXAM: COUGH ASSIGNMENT:
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.
SUBMISSION INFORMATION
Complete your Focused Exam: Cough DCE Assignment in Shadow Health via the Shadow Health link in Canvas.
Once you complete your assignment in Shadow Health, you will need to download your lab pass and upload it to the corresponding assignment in Canvas 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-passLinks to an external site.
Complete your documentation using the documentation template in your resources and submit it into your Assignment submission link below.
To submit your completed assignment, save your Assignment as WK5Assgn2+last name+first initial.
Then, click on Start Assignment near the top of the page.
Next, click on Upload File and select both files and then Submit Assignment for review.
By submitting this assignment, you confirm that you have complied with Walden University’s Code of Conduct including the expectations for academic integrity while completing the Shadow Health Assessment.
Rubric
NURS_6512_Week_5_DCE_Assignment_2_Rubric
NURS_6512_Week_5_DCE_Assignment_2_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeStudent 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.
60 to >55.0 pts
Excellent
DCE score>93
55 to >50.0 pts
Good
DCE Score 86-92
50 to >45.0 pts
Fair
DCE Score 80-85
45 to >0 pts
Poor
DCE Score <79… No DCE completed.
60 pts
This criterion is linked to a Learning OutcomeSubjective Documentation in Provider Note Template: Subjective narrative documentation in Provider Note Template 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.
20 to >15.0 pts
Excellent
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).
15 to >10.0 pts
Good
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).
10 to >5.0 pts
Fair
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).
5 to >0 pts
Poor
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.
20 pts
This criterion is linked to a Learning OutcomeObjective Documentation in Provider Notes – this is to be completed using the documentation template that is provided. 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).
20 to >15.0 pts
Excellent
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.
15 to >10.0 pts
Good
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.
10 to >5.0 pts
Fair
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.
5 to >0 pts
Poor
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.
20 pts
Total Points: 100
Note to the Writer :I will attach the transcripts and other data that will enable you complete this documentation
Patient has no allergy
He is an eight-year-old Puerto Rican male presented to the clinic with cough
No surgery and no known prior hospitalizations.Pneumonia last year,treated at urgent clinic
He is in 3rd grade,lives with parents,mother and father work while grandmother provides care.English primarily spoken at home but some Spanish used
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