NR 509 Week 1 Shadow Health History Assignment

NR 509 Week 1 Shadow Health History Assignment

NR 509 Week 1 Shadow Health History Assignment, Pre-brief:

Obtaining an accurate history is the critical first step in determining the etiology of a patient’s problem. A large percentage of the time, you will actually be able to make a diagnosis based on the history alone. The value of the history, of course, will depend on your ability to elicit relevant information. Your sense of what constitutes important data will grow exponentially as you practice your interviewing skills and through increased exposure to patients and illness…………………… Interviewing patients is an art and should remain an essential skill for successful practice.

In this activity, you will interview Tina Jones to collect data to assess Ms. Jones’ condition. You will also have the opportunity to educate and empathize with Tina to engage in effective therapeutic communication; create a problem listusing evidence from the data you collected; prioritize the identified problems to differentiate immediate from non-immediate care; plan how to best address the most important concern with further assessment, interventions, and patient education; and compare your documentation to model documentation.

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NR 509 Week 1 Shadow Health History Assignment

Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents to establish care and with a recent right foot injury. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Her speech is clear and coherent and she maintains eye contact throughout the interview. Shadow health respiratory assessment questions and transcript.

Reason for visit: Patient presents for an initial primary care visit today complaining of an infected foot wound.
| Overview
| Transcript
| Subjective Data Collection
| Objective Data Collection
| Education & Empathy
| Documentation / Electronic Health Record
| Information Processing
| Lab Pass: Certificate of Completion

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Week 1: Shadow Health History Assignment

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  • Due Jan 13, 2019 by 11:59pm
  • Points 50
  • Submitting a file upload

Pre-brief

Obtaining an accurate history is the critical first step in determining the etiology of a patient’s problem. A large percentage of the time, you will actually be able to make a diagnosis based on the history alone. The value of the history, of course, will depend on your ability to elicit relevant information. Your sense of what constitutes important data will grow exponentially as you practice your interviewing skills and through increased exposure to patients and illness. However, you are already in possession of the tools that will enable you to obtain a good history. Specifically, you must listen and ask appropriate questions to define the nature of a particular problem. In fact, seasoned clinicians occasionally lose sight of this important point, placing more reliance on the use of diagnostic testing rather than taking the time to listen to their patients. Interviewing patients is an art and should remain an essential skill for successful practice.

In this activity, you will interview Tina Jones to collect data to assess Ms. Jones’ condition. You will also have the opportunity to educate and empathize with Tina to engage in effective therapeutic communication; create a problem list using evidence from the data you collected; prioritize the identified problems to differentiate immediate from non-immediate care; plan how to best address the most important concern with further assessment, interventions, and patient education; and compare your documentation to model documentation.

Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents to establish care and with a recent right foot injury. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Her speech is clear and coherent and she maintains eye contact throughout the interview.

Reason for visit: Patient presents for an initial primary care visit today complaining of a right foot wound.

154744914001/13/201911:59pm

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Rubric

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Shadow Health Physical Assessment Rubric

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Shadow Health Physical Assessment Rubric
Criteria Ratings Pts
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Subjective Data, Organization, Communication, and Summary (DCE Score or transcript) _9172

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25.0 to >21.0 pts

Above Average- DCE Score greater than or equal to 93; Comprehensive introduction with expectations of exam verbalized; questions worded in a non-judgmental way; professional language exercised; questions well-organized; appropriate closing with summary of findings verbalized to patient.

_7235

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21.0 to >10.0 pts

Average- DCE Score greater than or equal to 86-92; Adequate introduction; some questions worded in a non-judgmental way; professional language mostly exercised; questions generally organized; somewhat complete closing.

_9258

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10.0 to >0.0 pts

Below Average- DCE Score greater than or equal to 80-85; Incomplete introduction; many questions worded in a judgmental way; some professional language exercised; questions somewhat organized; incomplete closing.

_2206

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0.0 to >0 pts

Unsatisfactory- DCE Score less than or equal to 79; Introduction missing; questions worded in a judgmental way; little professional language; questions unorganized; closing missing.

_4625

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pts

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Objective Data, Physical Examination, Interpretation of Findings, Assessment, and Documentation _5446

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20.0 to >16.0 pts

Above Average- Physical assessment documentation includes all relevant body systems; all pertinent normal and abnormal findings identified; documentation reflects professional language; treatment plan includes each of the following components: diagnostics, medication, education, consultation/referral, and follow-up planning.

_8504

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16.0 to >8.0 pts

Average- Physical assessment documentation lacks sufficient details pertaining to one or two relevant body systems; or identifies ? 50% of the pertinent normal and abnormal findings; or documentation lacks professional language; or treatment plan lacks one or two components (diagnostics, medication, education, consultation/referral, or follow-up planning).

_9311

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8.0 to >0.0 pts

Below Average- Physical assessment documentation lacks sufficient details pertaining to three or more relevant body systems; or identifies < 49% of the pertinent normal and abnormal findings; or documentation includes unprofessional language; or treatment plan lacks three or more components (diagnostics, medication, education, consultation/referral, or follow-up planning).

_1424

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0.0 to >0 pts

Unsatisfactory- No physical assessment documentation or no treatment plan.

_224

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Self-Reflection _3128

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5.0 to >3.0 pts

Above Average- Responds to three of the three reflection post questions; and provides analysis of performance; and reflection posts written using professional language; and reflection posts demonstrate insight.

_7104

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3.0 to >2.0 pts

Average- Responds to two of the three reflection post questions; or provides limited self-analysis of performance; or reflection posts are somewhat unclear related to the assignment and the student’s experience; or reflection posts lack insight.

_9169

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2.0 to >0.0 pts

Below Average- Responds to one of the three reflection post questions; or does not provide self-analysis of performance; or reflections are not related to the assignment and the student’s experience; or does not provide insight

_2706

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0.0 to >0 pts

Unsatisfactory- No reflection posts for the assignment.

_6746

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Total Points: 50.0 out of 50.0
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