Please review the complete instructions, resources and documentation tutorial.
Also, use the transcript and information provided and complete the health assessment on the attached template.
Name:
Section:
Week 4
Shadow Health Digital Clinical Experience Health History 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:
Health Maintenance:
Significant Family History (Include history of parents, maternal/paternal 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. 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:
Neck:
Breasts:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Psychiatric:
Neurological:
Skin:
Hematologic:
Endocrine:
© 2021 Walden University Page 1 of 1
© 20
21
Walden University
Page
1
of
2
Name:
Section:
Week 4
Shadow Health Digital Clinical Experience Health History 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:
Health Maintenance:
Significant Family History (
Include history of parents,
maternal/p
aternal
Grandparents, siblings,
and children):
Review of Systems:
Assignment 2: 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.
To Prepare
· Review 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. (See attachment)
· Review the DCE (Shadow Health) Documentation Template for Health History (Attached)
· Use the template (Attached) to complete your Documentation Notes for this DCE Assignment.
Assignment Instructions
:
Complete the Health History of Tina Jones (see below information and attached transcript “Tina Jones Transcript”) – To complete the assignment, please use the attached template.
Identifying Data & Reliability
Ms. Jones who is 28 yrs. old, obese African American single woman who presents to establish care and with a right foot injury.
She is the primary source of the history. Without contradiction, she freely provides specific details of her injury and of her visit. Her speech is clear and coherent. She maintains eye contact throughout the interview.
General Survey
Patient is 28 yr. Old single African American, alert, awake, and oriented x 3. She is pleasant; her speech is clear and coherent. Appears healthy, well-developed and well nourished. obese.
VS obtained BP 142/82, HR 86, RR 19, T 101.1, SPO2 99%, blood sugar 235. Weighs 90kg and BMI is 31.
Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene.
Chief Complaint
“I got this scrape on my foot a while ago, and I thought it would heal up on its own, but now it’s looking pretty nasty. And the pain is killing me!”
Symptoms: Right foot pain accompanied by drainage. Pain affects ability to walk or put weight on it. Also, affects sleep. Pain 7 out of 10.
Diagnosis: infected right foot wound.
History Of Present Illness
Tina fell going down the back steps of her house. Ms. Jones reports that a week ago she tripped while walking on concrete stairs outside, twisting her right ankle and scraping the ball of her foot and scraped the sole of her right foot. Her wound bled and she was able to stop the bleeding. She cleaned the wound and went to the ER fearing that she sprained her ankle. ER X-rayed her foot and reported no fracture seen. They gave her a prescription for a 5-day supply of Tramadol 50 mg. She cleaned her wound twice daily with
Advanced Heath Assessment Documentation Tutorial
In each of the Shadow Health (SH) Assignments, you will be asked to complete a narrative note as part of the grading criteria. Narrative or progress notes are often a new skill. This document is provided to assist students in understanding how to write a narrative note. Shadow Health refers to these notes as Provider Notes.
Documentation of patient care is essential to quality and safety of care. Much of the clinical documentation is completed electronically using point and click tools to describe the patient condition (Lindo, et al., 2016). Often computer prompts fall short of fully describing the patient condition. Other situations such as lack of technology, electrical outages, system hacking, failure of equipment, and any number of situations which may interfere with normal electronic documentation may require a narrative nurses/progress note. Nurses must be able to clearly communicate patient information with everyone on the health care team to ensure quality and safety of care (Lindo, et al., 2016).
Documentation must be clear, paint a picture of the patient, and provide measurable concise information in a timely manner. The information communicated must be able to be understood by others and provide enough information to understand if a change has occurred in the patient condition and to clearly communicate all treatments, interventions, and therapies received by the patient and/or planned for the patient. Documentation also serves as a legal record of care (Lippincott Williams and Wilkins, 2007).
Documentation begins with subjective data/information. This is information the patient, family member, or caregiver may provide if the patient is unable to communicate which includes such data as the history of present illness (HPI), the past history- allergies, medications, medical surgical & social and the review of systems (ROS). Objective data/information includes the physical exam, observations and measurements obtained during the examination of the patient. Objective data also includes vital signs, laboratory and diagnostic results (Bates, 2017, pg.7)
Subjective vs. Objective Data-As you begin to acquire data from the patient interview and physical exam, it is important to remember the difference between subjective and objective information. Symptoms are the subjective concerns of what the patient tells you of their experience. Signs are the objective findings from your observations. (Bates, 2017, pg.6). Sequence of data is documented in the manner it is collected from the sequence of the examination. Physical examination follows a cephalocaudal sequence with the cardinal techniques of inspection, palpation percussion and auscultation (Bates, 2018)
Subjective information assists in understanding the patient condition and provides a basis upon which the nurse d
8-2
Student Checklist
Copyright © 2015 by Mosby, an imprint of Elsevier Inc.
Copyright © 2015 by Mosby, an imprint of Elsevier Inc.
Ball: Seidel’s Guide to Physical Examination, 8th Edition
Chapter
0
8: Skin, Hair, and Nails
Student Checklist
Assessed Appropriately by Student?
Yes
No
Comments
I. Inspection and palpation of the skin
A. Color
B. Uniformity
C. Thickness
D. Symmetry
E. Hygiene
F. Lesions
1. Primary
2. Secondary
3. Size
4. Shape
5. Color
6. Texture
7. Elevation or depression
8. Attachment at base
9. Exudates
10. Configuration
11. Location and distribution
G. Odors
H. Moisture
I. Temperature
J. Texture
K. Turgor
L. Mobility
II. Inspection and palpation of the hair
A. Color
B. Distribution
C. Quantity
D. Texture
III. Inspection and palpation of the nails
A. Pigmentation, length, symmetry, and ridging or irregularities (redness, swelling, pain, exudate, warts, cysts, or tumors)
B. Measure nail base angle
C. Texture, firmness, thickness, uniformity, and adherence to nail bed
9/24/21, 1:22 AM Shadow Health – Tina Jones, Health History Flashcards | Quizlet
https://quizlet.com/356553232/shadow-health-tina-jones-health-history-flash-cards/ 1/65
Shadow Health – Tina Jones, Health History
Terms in this set (474)
Health History Tips & Tricks: …
Student: Hello!
Diana Shadow: Hi. I’m Preceptor Diana. I will explain the details of this
assignment and your objectives, just as a preceptor would in real life. Pay
close attention to this information as it will help guide your exam. At the
end of this prebrief, you will answer a short question about the upcoming
assignment. During the simulation, you may return to these instructions at
any time by scrolling to the top of your transcript.
Student: What is the situation?
Diana Shadow: Your patient is Tina Jones:, a 28-year-old African American
woman who has just been admitted to Shadow General Hospital for a
painful foot wound. Your role in this simulation is that of a healthcare
provider who will take Ms. Jones’ health history, a key component of her
admission process.
Student: What are my objectives in this
assessment?
Diana Shadow: A health history requires you to ask questions related to
Ms. Jones’ past and present health, from her current foot wound to her
pre-existing conditions. You will also want to review Ms. Jones’ systems,
psychosocial history, and family medical history. These assessments
together will give you a comprehensive picture of Ms. Jones’ overall
health. If you discover any disease states, ask about symptoms and the
patient’s experiences of them. Your questioning should cover a broad
array of the symptoms’ characteristics. Throughout the conversation, you
should educate and empathize with Ms. Jones when appropriate to
increase her health literacy and sense of well-being. Regardless of
whether you have assessed Ms. Jones previously, ask all questions that
are necessary for obtaining a complete health history. While you should
communicate with patients using accessible, everyday language, it is
standard practice to use professional medical terminology everywhere
else, such as in documenting physical findings and nursing notes. You
may complete the exam activities in any order and move between them
as needed. After obtaining Ms. Jones’ health history, you will complete an
information processing activity. You will identify and prioritize diagnoses,
then create a plan to address the identified diagnoses.
Shadow Health – Tina Jones, Health History
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