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.
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.
Name: NURS_6512_Week_9_DCE_Assignment_3_Rubric
Description: Note: To complete the Shadow Health assignments it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Week 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Do not copy any sample documentation as this is plagiarism. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score. You must pass this assignment with a total cumulative score of 79.5% or greater in order to pass this course.
| 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 <79No DCE completed. |
| Documentation in Provider Notes Area Subjective documentation of the comprehensive exam in Provider Notes is detailed, organized, and includes documentation of identifying data, general survey, reason for visit/chief complaint, history of present illness, medications, allergies, medical history, health maintenance, family history, social history, mental health history, and review of systems. The review of systems is clearly defined by each body system (skin, eyes, cardiac, etc.) and all conditions or illnesses asked of the patient are documented along with the patient response. | 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).orNo 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”. 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.orNo documentation provided. |
| Total Points: 100 |
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