Description
DIGITAL CLINICAL EXPERIENCE: FOCUSED EXAM: COUGH
In this DCE Assignment, you will conduct a focused exam related to cough in your DCE using the simulation tool, Shadow Health. You will determine what history should be collected from the patient, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.
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 consider the insights they provide related to ears, nose, and throat.
Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation within the Shadow Health platform. Review the examples also provided.
Review the DCE (Shadow Health) Documentation Template for Focused Exam: Cough 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 5 Focused Exam: Cough Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.
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?
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.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
Unformatted Attachment Preview
Name:
Section:
Week 5
Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC):
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.
General: Include any recent weight changes, weakness, fatigue, or fever, but do not
restate HPI data here.
HEENT:
Respiratory:
Cardiovascular/Peripheral Vascular:
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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.
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