NURS 6512 Week 7 Assessment of the Heart, Lungs, and Peripheral Vascular System
NURS 6512 Week 7 Assessment of the Heart, Lungs, and Peripheral Vascular System
Cardiovascular disease (CVD) is the largest cause of death worldwide. Accounting for 610,000 deaths annually (CDC, 2017), CVD frequently goes unnoticed until it is too late. Early detection and prevention measures can save the lives of many patients who have CVD. Conducting an assessment of the heart, lungs, and peripheral vascular system is one of the first steps that can be taken to detect CVD and many more conditions that may occur in the thorax or chest area.
This week, you will evaluate abnormal findings in the area of the chest and lungs. In addition, you will appraise health assessment techniques and diagnoses for the heart, lungs, and peripheral vascular system.
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NURS 6512 Week 7 Assessment of the Heart, Lungs, and Peripheral Vascular System Learning Objectives
Students will:
- Evaluate abnormal cardiac and respiratory findings
- Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the heart, lungs, and peripheral vascular system
Learning Resources for NURS 6512 Week 7 Assessment of the Heart, Lungs, and Peripheral Vascular System
- 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 14, “Chest and Lungs”This chapter explains the physical exam process for the chest and lungs. The authors also include descriptions of common abnormalities in the chest and lungs
- Chapter 15, “Heart”The authors of this chapter explain the structure and function of the heart. The text also describes the steps used to conduct an exam of the heart.
- Chapter 16, “Blood Vessels”This chapter describes how to properly conduct a physical examination of the blood vessels. The chapter also supplies descriptions of common heart disorders.
Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.
- Chapter 107, “X-Ray Interpretation: Chest (pp. 480–487) (previously read in Week 6; specifically focus on pp. 480–481)
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 8, “Chest Pain”
This chapter focuses on diagnosing the cause of chest pain and highlights the importance of first determining whether the patient is in a life-threatening condition. It includes questions that can help pinpoint the type and severity of pain and then describes how to perform a physical examination. Finally, the authors outline potential laboratory and diagnostic studies.Chapter 11, “Cough”
A cough is a very common symptom in patients and usually indicates a minor health problem. This chapter focuses on how to determine the cause of the cough by asking questions and performing a physical exam.Chapter 14, “Dyspnea”
The focus of this chapter is dyspnea, or shortness of breath. The chapter includes strategies for determining the cause of the problem through evaluation of the patient’s history, through physical examination, and through additional laboratory and diagnostic tests.Chapter 26, “Palpitations”
This chapter describes the different causes of heart palpitations and details how the specific cause in a patient can be determined.Chapter 33, “Syncope”
This chapter focuses on syncope, or loss of consciousness. The authors describe the difficulty of ascertaining the cause, because the patient is usually seen after the loss of consciousness has happened. The chapter includes information on potential causes and the symptoms of each.Note: Download the Student Checklists and Key Points to use during your practice cardiac and respiratory examination.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Chest and lungs: 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). Chest and lungs: 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.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Heart: 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). Heart: 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.
Katz, J. N., Lyons, N., Wolff, L. S., Silverman, J., Emrani, P., Holt, H. L., … Losina, E. (2011). Medical decision-making among Hispanics and non-Hispanic Whites with chronic back and knee pain: A qualitative study. BMC Musculoskeletal Disorders, 12(1), 78–85.
This study examines the medical decision making among Hispanics and non-Hispanic whites. The authors also analyze the preferred information sources used for making decisions in these populations.
Smuck, M., Kao, M., Brar, N., Martinez-Ith, A., Choi, J., & Tomkins-Lane, C. C. (2014). Does physical activity influence the relationship between low back pain and obesity? The Spine Journal, 14(2), 209–216.
Shiri, R., Solovieva , S., Husgafvel-Pursiainen, K., Telama, R., Yang, X., Viikari, J., Raitakari, O. T., & Viikari-Juntura, E. (2013). The role of obesity and physical activity in non-specific and radiating low back pain: The Young Finns study. Seminars in Arthritis & Rheumatism, 42(6), 640–650.
McCabe, C., & Wiggins, J. (2010a). Differential diagnosis of respiratory disease part 1. Practice Nurse, 40(1), 35–41.
This article describes the warning signs of impending deterioration of the respiratory system. The authors also explain the features of common respiratory conditions.
McCabe, C., & Wiggins, J. (2010b). Differential diagnosis of respiratory diseases part 2. Practice Nurse, 40(2), 33–41.
The authors of this article specify how to identify the major causes of acute breathlessness. Additionally, they explain how to interpret a variety of findings from respiratory investigations.
Shadow Health Support and Orientation Resources
Use the following resources to guide you through your Shadow Health orientation as well as other support resources:
Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file]. Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY
Shadow Health. (n.d.). Shadow Health help desk. Retrieved from https://support.shadowhealth.com/hc/en-us
Document: Shadow Health. (2014). Useful tips and tricks (Version 2) (PDF)
Document: Student Acknowledgement Form (Word document)
Note: You will sign and date this form each time you complete your DCE Assignment in Shadow Health to acknowledge your commitment to Walden University’s Code of Conduct.
Document: DCE (Shadow Health) Documentation Template for Focused Exam: Chest Pain (Word document)
Use this template to complete your Assignment 1 for this week.
Optional Resource
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.
- Chapter 8, “The Chest: Chest Wall, Pulmonary, and Cardiovascular Systems; The Breasts” (Section 1, “Chest Wall, Pulmonary, and Cardiovascular Systems,” pp. 302–433)Note:Section 2 of this chapter will be addressed in Week 10.This section of Chapter 8 describes the anatomy of the chest wall, pulmonary, and cardiovascular systems. Section 1 also explains how to properly conduct examinations of these areas.
Assignment 1: Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System 
Take a moment to observe your breathing. Notice the sensation of your chest expanding as air flows into your lungs. Feel your chest contract as you exhale NURS 6512 Week 7 Assessment of the Heart, Lungs, and Peripheral Vascular System. How might this experience be different for someone with chronic lung disease or someone experiencing an asthma attack?
In order to adequately assess the chest region of a patient, nurses need to be aware of a patient’s history, potential abnormal findings, and what physical exams and diagnostic tests should be conducted to determine the causes and severity of abnormalities.
In this DCE Assignment, you will conduct a focused exam related to chest pain using the simulation too, Shadow Health. Consider how a patient’s initial symptoms can result in very different diagnoses when further assessment is conducted.
To Prepare for NURS 6512 Week 7 Assessment of the Heart, Lungs, and Peripheral Vascular System
- Review this week’s Learning Resources and the Advanced Health Assessment and Diagnostic Reasoning media program and consider the insights they provide related to heart, lungs, and peripheral vascular system.
- 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 Focused Exam: Chest Pain 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 7 DCE Focused Exam: Chest Pain Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.
- Consider what history would be necessary to collect from the patient.
- 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?
DCE Focused Exam: Chest Pain Assignment: NURS6512 Week 7: Assessment of the Heart, Lungs, and Peripheral Vascular System
Complete the following in Shadow Health:
- Cardiovascular Concept Lab (Recommended but not required)
- Abdominal Concept Lab (Recommended but not required)
- Episodic/Focused Note for Focused Exam: Chest Pain
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 7 Day 7 deadline.
NURS 6512 Week 7 Assessment of the Heart, Lungs, and Peripheral Vascular System Submission and Grading Information
By Day 7 of Week 7
- Complete your Focused Exam: Chest Pain 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.
Brian Foster Focused Exam: Chest Pains Care Plan : 11 of 12 (91.7%)
International classification for nursing practice (ICNP) nursing diagnoses (v2019_06_27) [Data set]. (2019). International Council of Nurses (ICN). https://www.icn.ch/what-we-do/projects/ehealth-icnptm/icnp-download
Diagnosis
|
Student Response |
Model Answer |
Explanation |
Points Earned |
|
lack of knowledge of post-cardiac procedure care |
lack of knowledge of post-cardiac procedure care |
Mr. Foster has reported his previous acute pain was at 0/10; his current healthcare needs are for education on relevant topics. |
1 out of 1 |
Signs & Symptoms
|
Student Response |
Model Answer |
Explanation |
Points Earned |
|
not currently on cardiac diet |
not currently on cardiac diet |
Brian’s stent was just placed, indicating a need for recovery instructions. In addition, his lifestyle is sedentary and his diet isn’t cardiac-friendly, so he has room to learn about the link between heart health and diet & exercise. NURS6512 Week 7: Assessment of the Heart, Lungs, and Peripheral Vascular System |
1 out of 1 |
|
new placement of cardiac stent |
new placement of cardiac stent |
Brian’s stent was just placed, indicating a need for recovery instructions. In addition, his lifestyle is sedentary and his diet isn’t cardiac-friendly, so he has room to learn about the link between heart health and diet & exercise. |
1 out of 1 |
|
previous pain character (tight and uncomfortable) |
sedentary lifestyle prior to hospitalization |
Brian’s stent was just placed, indicating a need for recovery instructions. In addition, his lifestyle is sedentary and his diet isn’t cardiac-friendly, so he has room to learn about the link between heart health and diet & exercise. |
0 out of 1 |
Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor.
|
Prompt |
Student Response |
Model Answer |
Explanation |
|
How can a patient’s knowledge of their health risks affect their health? |
A patient’s understanding of their health risks makes them aware of the warning signs to look for, and enables them to practice appropriate health habits. The knowledge also helps them to know when to seek medical help. NURS6512 Week 7: Assessment of the Heart, Lungs, and Peripheral Vascular System |
A patient’s understanding of their health risks can lead them to be wary of warning signs, practice appropriate health habits, and know when to reach out to medical professionals for help. |
Your role as a healthcare provider is not limited to physical and medical interventions; knowing why and how to educate your patients is a crucial part of impacting their health. |
Short-Term Goal
|
Student Response |
Model Answer |
Explanation |
Points Earned |
|
Patient will verbalize understanding of post-stent care and appropriate diet and exercise for heart healthy lifestyle prior to discharge. |
Patient will verbalize understanding of post-stent care and appropriate diet and exercise for heart healthy lifestyle prior to discharge. |
Having a patient verbalize their instructions lets you check for things they might have missed. In addition, if a patient doesn’t consent to their instructions, further persuasion should be made. |
0.5 out of 0.5 |
Interventions
|
Student Response |
Model Answer |
Explanation |
Points Earned |
|
Instruct patient that if chest pain develops, he should alert staff immediately |
Instruct patient that if chest pain develops, he should alert staff immediately |
These interventions teach Brian appropriate stent site monitoring and heart-healthy diet & exercise tips. Timing is appropriate in interventions; chest pain, especially after a procedure that should mitigate it, should be reported to a provider immediately. Similarly, while Brian can begin his diet anytime, beginning a new exercise regimen right after his surgery increases his risk of injury. |
1 out of 1 |
|
Instruct patient to begin exercise regimen after a week: low-impact walking, 15-20 minutes, 3 times a week, and increase intensity and frequency as tolerated |
Instruct patient to begin exercise regimen after a week: low-impact walking, 15-20 minutes, 3 times a week, and increase intensity and frequency as tolerated |
These interventions teach Brian appropriate stent site monitoring and heart-healthy diet & exercise tips. Timing is appropriate in interventions; chest pain, especially after a procedure that should mitigate it, should be reported to a provider immediately. Similarly, while Brian can begin his diet anytime, beginning a new exercise regimen right after his surgery increases his risk of injury. |
1 out of 1 |
|
Instruct patient to begin cardiac diet immediately, including reduction of salt and red meat intake |
Instruct patient to begin cardiac diet immediately, including reduction of salt and red meat intake |
These interventions teach Brian appropriate stent site monitoring and heart-healthy diet & exercise tips. Timing is appropriate in interventions; chest pain, especially after a procedure that should mitigate it, should be reported to a provider immediately. Similarly, while Brian can begin his diet anytime, beginning a new exercise regimen right after his surgery increases his risk of injury. |
1 out of 1 |
|
Instruct patient to monitor puncture site for signs of complication: bleeding, redness, swelling, warmth, and/or drainage |
Instruct patient to monitor puncture site for signs of complication: bleeding, redness, swelling, warmth, and/or drainage |
These interventions teach Brian appropriate stent site monitoring and heart-healthy diet & exercise tips. Timing is appropriate in interventions; chest pain, especially after a procedure that should mitigate it, should be reported to a provider immediately. Similarly, while Brian can begin his diet anytime, beginning a new exercise regimen right after his surgery increases his risk of injury. |
1 out of 1 |
Intervention Rationale
Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor.
|
Prompt |
Student Response |
Model Answer |
Explanation |
|
In 1 or 2 sentences, explain how your selected interventions work to accomplish your goal. |
These interventions will help Brian stay keen of any problem with the stent site healing, so that he knows when to contact his care provider. He also receives teaching on diet and exercise routines for his cardiovascular health, ensuring that he only makes these changes at the appropriate time during his post-surgery recovery. |
These interventions help Brian stay alert for problems in his puncture site healing, so that he knows when to contact his provider. Brian also receives teaching on concrete ways to diet and exercise for his cardiovascular health, while ensuring he makes his changes at an appropriate time during his surgery recovery. |
It is important to give a patient the tools they need to stay healthy in the short-term (monitoring their surgical site) and in the long-term (building habits that stave off cardiovascular disease). |
Data Collections
|
Student Response |
Model Answer |
Explanation |
Points Earned |
|
Ask patient to agree to and verbalize his instructions for diet and exercise |
Ask patient to agree to and verbalize his instructions for diet and exercise |
After all patient instructions have been made, make sure your patient agrees to them and is able to verbalize them back, letting you spot any details they’ve missed. |
0.5 out of 0.5 |
|
Ask patient to agree to and verbalize his stent-related care instructions |
Ask patient to agree to and verbalize his stent-related care instructions |
After all patient instructions have been made, make sure your patient agrees to them and is able to verbalize them back, letting you spot any details they’ve missed. |
0.5 out of 0.5 |
Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor.
|
Prompt |
Student Response |
Model Answer |
Explanation |
|
A patient should understand their nursing diagnosis and the rationale behind it to increase their sense of involvement and to identify areas for future improvement. |
Mr Brian, you now have a newly placed stent which will require some at-home recovery care from you, which you are yet to be briefed on. In addition, you have not been taught on heart-healthy practices you should adhere to in order to prevent future cardiac diseases. |
Brian, your recently placed cardiac stent will require some at-home recovery care from you, which you haven’t yet been filled in on. In addition, you haven’t been taught about some heart-healthy practices that will prevent future cardiac diseases. |
Explain the rationale behind your nursing diagnosis. |
|
You should communicate the care plan to the patient, allowing them to have involvement and agency in their own healthcare. |
Brian, my goal for you is, that by the end of your stay, you will agree to and be able to verbalize back the instructions I will provide on post-stent care and long-term heart health. I am going to educate you on these subjects, with some help from your provider, who will then review your medication regimen with you. |
Brian, my goal for you is, by the end of your stay, to have you agree to and verbalize back the instructions you’ll receive on post-stent care and long-term heart health. I’m going to educate you on these subjects. At the end of your hospitalization, I’ll have you repeat back your instructions to make sure you’ve got them down. |
Explain your goal for Mr. Foster and the interventions and data collections through which you will achieve it. |
|
Educating Mr. Foster on how to monitor his puncture site will help ensure that any potential complications, such as infection, are caught quickly, and can then be addressed before they worsen. |
Monitor the stent site for signs of infection, that is, redness, swelling, warmth, or drainage. Timing is everything. Should you experience any chest pain, immediately report it to your primary provider. Begin your heart-healthy diet immediately, and make sure to limit your salt and caffeine intake. Do not start exercise right away, as this may increase your risk of further injury. Wait until one week, before starting with simple exercises such as walking around the compound. |
I’d like you to keep an eye on your puncture site to make sure it’s healing properly. Watch out for bleeding or any signs of infection, such as redness, swelling, warmth, or drainage. |
Educate Mr. Foster on how to care for and monitor his puncture site. |
|
It’s important to educate Mr. Foster on what to do if he develops further chest pain so that he doesn’t wait or hesitate in a potentially life-threatening situation. |
If you develop any chest pain, please report it immediately to your primary care provider. |
If you feel any more chest pain, I’d like you to immediately alert staff so we can help. Don’t hesitate to let someone know. |
Educate Mr. Foster about what to do if chest pain develops. |
|
Educating Mr. Foster on his new cardiac diet helps increase his likelihood of understanding and complying with the diet. In addition, having a conversation about changes in lifestyle gives you an opportunity to address any questions or concerns he may have. |
Your cardiac diet, which you must start following today, comprises vegetables, whole grains, and oily fish. Eliminate or limit all processed foods that are high in sugar and salt from your diet. |
I’d strongly advise you to begin a cardiac diet as soon as possible. In general, you’ll want to reduce your intake of red meat and salt as much as you can. |
Educate Mr. Foster on how to follow a cardiac diet, as well as how soon he should begin. |
|
Educating Mr. Foster on his new exercise regimen helps increase his likelihood of understanding and complying with the recommended exercise. In addition, having a conversation about changes in lifestyle gives you an opportunity to address any questions or concerns he may have. |
After one week, begin routine exercise of walking around the house and the compound. Once you are comfortable with this, incorporate mild aerobic exercises to get your heart pumping well. Later, try out strength training, not more than 2 days per week. Include stretching and flexibility. Practice only low or moderate intensity exercise. |
After a week, I recommend that you begin a regular exercise regimen. Try taking low-impact walks three times a week for about fifteen to twenty minutes each. If you feel like you’re tolerating that well, you can increase the intensity and frequency of your walks. |
Educate Mr. Foster on how to follow a heart-healthy exercise program. |
|
Asking the patient to verbalize what they’ve learned is an important part of education. If they forget or misunderstand anything, this is a good opportunity to correct them. |
Kindly state back the instructions for diet and exercise? |
Mr. Foster, would you please repeat what we’ve discussed about your new diet and exercise recommendations? That way, we can make sure you’re not missing anything. |
Ask Mr. Foster to state back his instructions for diet and exercise. |
|
Asking the patient to verbalize what they’ve learned is an important part of education. If they forget or misunderstand anything, this is a good opportunity to correct them. |
State back the instructions for caring for your puncture site. |
Mr. Foster, would you please repeat what we’ve discussed about your puncture site care instructions? That way, we can make sure you’re not missing anything. |
Ask Mr. Foster to state back his puncture site-related care instructions. |
|
Student Response |
Model Answer |
Explanation |
Points Earned |
|
Fully |
Fully |
Mr. Foster’s repetition of his instructions shows a full and detailed knowledge of them; furthermore, he consents to making these new choices. Your goal has been fully achieved. |
2.5 out of 2.5 |
Intervention & Evaluation Rationale
Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor.
|
Prompt |
Student Response |
Model Answer |
Explanation |
|
Your goal was that the patient, by the end of their hospitalization, verbalizes and agrees to instructions for their post-stent care and heart healthy practices. Have you achieved your goal? |
The goal for Brian has been fully achieved. he has agreed to and has verbalized the comprehensive instructions for post-stent recovery and long-term heart health procedures, without missing any detail. |
The goal for Mr. Foster has been fully achieved; he has agreed to and verbalized detailed and comprehensive knowledge of his instructions for post-stent recovery and long term heart-health, without missing any details. |
A patient’s verbalization of their instructions shows to what extent they understand and remember those instructions. |
NURS 6512 Week 7 Assessment of the Heart, Lungs, and Peripheral Vascular System Rubric Detail
Select Grid View or List View to change the rubric’s layout.
| 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: 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 |
|---|
Also Read: NURS6512 Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat
