Shadow Health Digital Clinical Experience Health History Documentation Paper

Shadow Health Digital Clinical Experience Health History Documentation Paper

Shadow Health Digital Clinical Experience Health History Documentation Paper

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

Chief Complaint (CC): A painful wound on the right foot.

History of Present Illness (HPI): An African American woman named Tina, 28, alleges that a week ago while walking, she stumbled over a concrete step and twisted her right ankle, scraping the ball of her foot in the process. She went to a neighboring emergency unit, where an X-ray was ordered and found to be negative. Tramadol was nonetheless provided to her to help with the discomfort. She says she cleans the wound twice daily, applies antibiotic cream, and wraps it in a bandage. Even though the pain and swelling at the location of the injury have fully subsided, she claims that the bottom of her foot is still quite uncomfortable. She describes the discomfort as being weight-bearing, throbbing, and intense. But, the discomfort in her ankle has already subsided. She continues to rate the pain as 7/10 even after a recent dose of tramadol. She gives the pain when bearing weight, a 9 out of 10. She describes a swollen football that has become redder over the last two days. A day before the current appointment, the wound was already dripping with an odorless discharge. She claims that recently, her shoes have been uncomfortable, so she has started wearing slippers instead. Her fever was 1020F last night. She, though, denies having been unwell recently. She reports an increase in hunger and an unintentional 10-pound weight reduction over the past month. She asserts that her diet and energy levels have not changed.

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Medications:

1. Ibuprofen 600mg orally three times each day for menstrual cramps.
2. Acetaminophen 500-100 mg orally, as needed for headaches.
3. Tramadol 50 mg orally twice a day if foot pain persists.
4. Albuterol 90mcg/spray multiple-dose inhalation up to two puffs every 6 hours for wheeze caused by cat allergies. She had last used the medication around three days before the current appointment.

Allergies:

1. There are no documented latex or food sensitivities.
2. Penicillin hypersensitivity
3. Establishes dust and cat allergies
4. Allergic reaction: runny nose, puffy and itchy eyes, and worsening asthma symptoms.

Past Medical History (PMH): At the age of two and a half years, was given an asthma diagnosis. Two to three times each week, she utilizes an Albuterol inhaler to control her symptoms when she is exposed to dust or cats. She was exposed to cats three days ago, and she used an inhaler, which was quite efficient in controlling the symptoms. She was hospitalized for asthma the last time she was in high school. She, on the other hand, denies ever being intubated. When she was 24, she was diagnosed with diabetes mellitus. She had been taking metformin but had discontinued roughly three years ago because of flatulence adverse effects. She also reports that taking the tablets and checking her blood glucose simultaneously has been exhausting. She denies that she has been monitoring her blood glucose levels since then. She claims that the last time her levels of sugar in her blood soared was a week ago at the emergency department.

Past Surgical History (PSH): None

Sexual/Reproductive History: At the age of 11, she had her first menstrual cycle. heterosexual; first sexual experience occurred at the age of 18. denies ever becoming a mother. Menstrual cycles have been heavy and irregular in the last year, lasting 9 to 10 days every 4 to 8 weeks, with the most recent period starting around 3 weeks before the current appointment. She acknowledges using oral contraceptives mostly in past, but she is now single. denies wearing condoms when engaging in sexual activity. No reported history of STIs. The patient claims to have never had an HIV/AIDS test before. Her previous pap smear exam was roughly four years ago, according to her.

Personal/Social History: The patient enjoys going to clubs and drinking alcohol on occasion. Her bachelor’s degree is in accountancy. She has a loving family and friends. There will be no cigarette or marijuana use. He goes to a Baptist church.

Immunization History: She had a tetanus booster last year. Her influenza vaccination is out of date. Her human papillomavirus vaccination was not given to her. She received her meningococcal vaccine when she was still attending college and believes she was immunized as a teenager.

Health Maintenance: No physical activity. She recalls her nutrition over the previous 24 hours. The day before the current visit, he claims to have skipped breakfast and had a lunch of a sandwich and chicken or steak for dinner. She brings mostly French fries or pretzels as snacks. Smoke detectors have been put in her home. She admits to wearing a seatbelt in the automobile but denies riding a bike. He denies wearing sunblock. Her father’s firearms are still in the house, but they are locked up in their parents’ room.

Significant Family: The mother, who is 50, has high cholesterol. Her Father died in an automobile accident when he was 58 years old. Diabetes and hypertension were present. Her sister suffers from asthma. Brother has no medical issues. At the age of 73, her maternal granny passed away after a stroke. At the age of 78, her maternal grandfather passed away after a stroke. At the age of 65, her paternal grandfather passed away from colon cancer. Her paternal grandmother is still living. There is no history of addiction, mental health problems, headaches, malignancies, or thyroid problems.

Review of Systems:

General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.

General: Tina is polite, friendly, and well-organized in general. She is also well-groomed, responds well to queries, and is not depressed.

HEENT: The patient complains of headaches when studying. He has impaired eyesight but does not use glasses. There is no runny nose or ear discharge. There is no swelling or painful throat.

Neck: There are no lymphatic problems or inflammation around the neck.

Breasts: There is no nipple discharge or soreness in the breasts.

Respiratory: No breathlessness, chest pain, or tightness.

Cardiovascular/peripheral: There are no blood clots in the cardiovascular or peripheral systems.

Gastrointestinal: No constipation, bowel disturbances, or watery stools. The patient feels thirsty and has an increased appetite.

Gastrointestinal: No bowel changes, constipation, or watery stool. The patient has an increased appetite and is thirsty.

Genitourinary: The patient’s periods are irregular.

Musculoskeletal: No back or muscular discomfort. Psychiatric: There are no signs of depression or hallucinations.

Neurological: There is no tingling or dizziness.

Skin: Acne-free skin with no chin hair.

Hematologic: There is no history of significant bleeding in the patient. There is no sweating, shivers, or fever.

Endocrine: Denies heat or cold intolerance.

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Digital Clinical Experience (DCE): Health History Assessment

In Week 3, you began your DCE: Health History Assessment. For this week, you will complete this Health History Assessment in your simulation tool, Shadow Health and finalize for submission.

Resources

 

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCE

To Prepare

• Review this week’s Learning Resources as well as the Taking a Health History media program in Week 3, and consider how you might incorporate these strategies. Download and review the Student Checklist: Health History Guide and the History Subjective Data Checklist, provided in this week’s Learning Resources, to guide you through the necessary components of the assessment.
• Review the DCE (Shadow Health) Documentation Template for Health History 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 Shadow Health Student Orientation media program and the Useful Tips and Tricks document provided in the week’s Learning Resources to guide you through Shadow Health.
• Review the Week 4 DCE Health History Assessment Rubric, provided in the Assignment submission area, for details on completing the Assignment.

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 Health History Assessment:

Complete the following in Shadow Health:

Orientation

• DCE Orientation (15 minutes)
• Conversation Concept Lab (50 minutes, Required)

Health History

• Health History 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 4 Day 7 deadline.

submission information

• Complete your Health Assessment DCE assignments 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.
• 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 WK4Assgn2+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.

 

 

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.

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Rubric

NURS_6512_Week_4_DCE_Assignment_2_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 ptsExcellent DCE score>93 55 to >50.0 ptsGood DCE Score 86-92 50 to >45.0 ptsFair DCE Score 80-85 45 to >0 ptsPoor 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.	40 to >35.0 ptsExcellent 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). 35 to >30.0 ptsGood 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). 30 to >25.0 ptsFair 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). 25 to >0 ptsPoor 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.	40 pts
Total Points: 100