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DIGITAL CLINICAL EXPERIENCE: COMPREHENSIVE (HEAD-TO-TOE) PHYSICAL ASSESSMENT
Throughout this course, you were encouraged to practice conducting various physical assessments on multiple areas of the body, ranging from the head to the toes. Each of these assessments, however, was conducted independently of one another. For this DCE Assignment, you connect the knowledge and skills you gained from each individual assessment to perform a comprehensive head-to-toe physical examination in your Digital Clinical Experience.
RESOURCES
Be sure to review the Learning Resources before completing this activity. Click the weekly resources link to access the resources. WEEKLY RESOURCES
TO PREPARE
Review this week’s Learning Resources, and download and review the Physical Examination Objective Data Checklist as well as the Student Checklists and Key Points documents related to neurologic system and mental status.
Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation with the Shadow Health platform. Review the examples also provided.
Review the DCE (Shadow Health) Documentation Template for Comprehensive (Head-to-Toe) Physical Assessment 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 9 DCE Comprehensive Physical Assessment Rubric provided in the Assignment submission area for details on completing the Assessment in Shadow Health.
Also, your Week 9 Assignment 3 should be in the Complete SOAP Note format. Refer to Chapter 2 of the Sullivan text and the Week 4 Complete Physical Exam template and use the template below for your submission.
Week 9 Shadow Health Comprehensive SOAP Note Documentation Template Download Week 9 Shadow Health Comprehensive SOAP Note Documentation Template
Note: There are 2 parts to this assignment – the lab pass and the documentation. You must achieve a total score of 80% in order to pass this assignment. Carefully review the rubric and video presentation in order to fully understand the requirements of this assignment.
DCE COMPREHENSIVE PHYSICAL ASSESSMENT:
Complete the following in Shadow Health:
Episodic/Focused Note for Comprehensive Physical Assessment of Tina Jones (180 minutes)
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 9 Day 7 deadline. SUBMISSION INFORMATION
Complete your Comprehensive (Head-to-Toe) Physical Assessment 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-pass Links to an external site.
Review the Week 9 DCE Health History Assessment Rubric, provided in the Assignment submission area, for details on completing the Assignment.
Links to an external site.Complete your documentation using the documentation template in your resources and submit it into your Assignment submission link.
To submit your completed assignment, save your Assignment as WK9Assgn3+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.
Note: You must pass this assignment with a minimum score of 80% in order to pass the class. Once submitted, there are not any opportunities to revise or repeat this assignment.
Rubric
NURS_6512_Week_9_DCE_Assignment_3_Rubric
NURS_6512_Week_9_DCE_Assignment_3_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning Outcome 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.
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 Outcome Subjective 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 Outcome Objective 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).
You also have your final DCE which is a Head-to-Toe Comprehensive Physical Exam due this week. As per the syllabus and rubric, you must pass this assignment with a combined score of 80 or better (lab pass & documentation template) to pass the course. So please do not leave a section unanswered. Remember the physical exam goes under the objective section and the diagnoses are under the assessment section. If you are confused, please reach out to me. Please thoroughly document this comprehensive visit. If you attempt to use the SOAP format, be sure to include everything in each section. But I advise you to use the template provided to make sure you do not miss a section.
Please do not add any mnemonics, bullet points or write your entire note in bold. Points will be taken off if you continue to do this. Also do not write within normal limits in your physical exam or review of systems. You should write out the symptoms (ROS) or exam findings (Physical Exam).
NB
Please if you u are not familiar with subject topic please do not take this paper
It is basically a proofread as I have given you all the materials needed
I need at least 3 references in text for the plan of care references must be in APA
References must be less than 5 years
No dates references not accepted
Will verify plagiarism I know the order says 3 pages but I’m providing you with enough information to be able to come out with a lengthy paper