NURS 6512 Assignment 2 Week 3: Digital Clinical Experience (DCE) Health History Assessment IN

Sample Answer for NURS 6512 Assignment 2 Week 3: Digital Clinical Experience (DCE) Health History Assessment IN Included After Question

Properly identifying the cause and type of a patient’s skin condition involves a process of elimination known as differential diagnosis. Using this process, a health professional can take a given set of physical abnormalities, vital signs, health assessment findings, and patient descriptions of symptoms, and incrementally narrow them down until one diagnosis is determined as the most likely cause.

In this Lab Assignment, you will examine several visual representations of various skin conditions, describe your observations, and use the techniques of differential diagnosis to determine the most likely condition.

To Prepare

  • Review the Skin Conditions document provided in this week’s Learning Resources, and select one condition to closely examine for this Lab Assignment.
  • Consider the abnormal physical characteristics you observe in the graphic you selected. How would you describe the characteristics using clinical terminologies?
  • Explore different conditions that could be the cause of the skin abnormalities in the graphics you selected.
  • Consider which of the conditions is most likely to be the correct diagnosis, and why.
  • Search the Walden library for one evidence-based practice, peer-reviewed article based on the skin condition you chose for this Lab Assignment.
  • Review the Comprehensive SOAP Exemplar found in this week’s Learning Resources to guide you as you prepare your SOAP note.
  • Download the SOAP Template found in this week’s Learning Resources, and use this template to complete this Lab Assignment.

The Lab Assignment

  • Choose one skin condition graphic (identify by number in your Chief Complaint) to document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format rather than the traditional narrative style. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in this week’s Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.
  • Use clinical terminologies to explain the physical characteristics featured in the graphic. Formulate a differential diagnosis of three to five possible conditions for the skin graphic that you chose. Determine which is most likely to be the correct diagnosis and explain your reasoning using at least three different references, one reference from current evidence-based literature from your search and two different references from this week’s Learning Resources.

By Day 7 of Week 4

Submit your Lab Assignment.

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A Sample Answer For the Assignment: NURS 6512 Assignment 2 Week 3: Digital Clinical Experience (DCE) Health History Assessment IN

Title: NURS 6512 Assignment 2 Week 3: Digital Clinical Experience (DCE) Health History Assessment IN

Identifying Data 

Ms. Jones, a pleasant 28-year-old lady of African American descent, arrived at the clinic to begin treatment for a recent injury to her right foot. She identified herself as the primary information provider. Throughout the evaluation, she speaks well and coherently while being open with her communication. She maintains amazing eye contact the whole exam. 

General Survey 

The patient is awake and has a good sense of place, time, and other people. As she takes a seat upright, she doesn’t exhibit any indications of concern. She has dressed appropriately for her age and appears to be well-developed, fed, and quite sanitary. 

Subjective Data 

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

History of Present Illness: 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.  

Medications 

  1. Ibuprofen 600mg orally three times each day for menstrual cramps. 
  1. Acetaminophen 500-100 mg orally, as needed for headaches. 
  1. Tramadol 50 mg orally twice a day if foot pain persists. 
  1. 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. 
  1. Penicillin hypersensitivity 
  1. Establishes dust and cat allergies 
  1. Allergic reaction: runny nose, puffy and itchy eyes, and worsening asthma symptoms. 

Medical History 

  • 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.  
  • Surgery: None 
  • OB/GYN: 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. Has no history of STIs and denies ever having had an HIV/AIDS test before. Her previous pap smear exam was roughly four years ago, according to her. 

Health Maintenance 

  • Her most recent eye exam was when she was a little child. A few years ago, she had her most recent dental examination. Two years ago, a PPD test turned out to be negative. 
  • Physical activity: No physical activity 
  • Nutrition: 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. 
  • Vaccination: 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 youngster.  
  • Safety: 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.  

Family History: 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. 

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. 

 

Review of Symptoms (ROS) 

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. 

Objective data 

Vital signs: Wt., 90 kg. BMI 31, HR 86: BP 142/82 RR 19: Pulse oximetry 99%: T 101.1.  

Diagnostic findings: Wound dimensions are 2cm x 1.5cm, with a depth of 2.5mm. Serosanguinous discharge from the right ball of the foot, as well as red wound margins. There was no monitoring and no edema. Erythema around the wound is mild. 

Differential Diagnosis  

  1. Asthma: This respiratory disorder develops when the small airways release excessive mucus, making breathing difficult. Breathlessness, wheezing, coughing, and difficulty sleeping are all symptoms (Nakamura et al., 2020). Flu, colds, and allergens such as dust, pollen, and animal hair can all induce asthma. Drugs can be used to treat the illness. Because the patient is prone to cat dander and dust, asthma is the major diagnosis. She further complains of breathlessness and wheezing, both of which are asthma symptoms. 
  1. Local infection of the skin and subcutaneous tissue of the foot: The bacterium staphylococcus aureus is the primary cause of this illness. The disorder develops because of skin irritation generated by wounds or cuts (Polk et al., 2021). When the patient reports a wound on her right leg, she may have this ailment.  
  1. Acute pain of the foot: A fall is usually the main reason for this ailment. Pain that comes on suddenly and severely (Chung et al., 2021). The ailment may be temporary or persistent for the sufferer. The patient reported that she is in significant pain, rating it a 7 out of 10.  
  1. Uncontrolled type 2 diabetes: This sickness causes the patient to urinate often and lose weight. She may have unmanaged type 2 diabetes since she had an excessive thirst and quit taking her diabetic medicines three years ago (Pamungkas et al., 2019). Uncontrolled diabetes might result from the same.  
  1. Polycystic ovary syndrome: An excessive amount of androgen hormones in one’s system is the root cause of this illness. Period irregularities are a defining feature of the illness (Azziz, 2018). The woman claims to have irregular cycles every three months; thus, she most definitely has this issue. 

 

References: 

Azziz, R. (2018). Polycystic Ovary Syndrome. Obstetrics & Gynecology, 132(2), 321–336. https://doi.org/10.1097/aog.0000000000002698  

Chung, C. L., Paquette, M. R., & DiAngelo, D. J. (2021). Impact of a dynamic ankle orthosis on acute pain and function in patients with mechanical foot and ankle pain. Clinical Biomechanics, 83, 105281. https://doi.org/10.1016/j.clinbiomech.2021.105281  

Polk, C., Sampson, M. M., Roshdy, D., & Davidson, L. E. (2021). Skin and Soft Tissue Infections in Patients with Diabetes Mellitus. Infectious Disease Clinics of North America, 35(1), 183–197. https://doi.org/10.1016/j.idc.2020.10.007  

Nakamura, Y., Tamaoki, J., Nagase, H., Yamaguchi, M., Horiguchi, T., Hozawa, S., Ichinose, M., Iwanaga, T., Kondo, R., Nagata, M., Yokoyama, A., & Tohda, Y. (2020). Japanese guidelines for adult asthma 2020. Allergology International, 69(4), 519–548. https://doi.org/10.1016/j.alit.2020.08.001 

Pamungkas, R. A., Chamroonsawasdi, K., Vatanasomboon, P., & Charupoonphol, P. (2019). Barriers to Effective Diabetes Mellitus Self-Management (DMSM) Practice for Glycemic Uncontrolled Type 2 Diabetes Mellitus (T2DM): A Socio Cultural Context of Indonesian Communities in West Sulawesi. European Journal of Investigation in Health, Psychology and Education, 10(1), 250–261. https://doi.org/10.3390/ejihpe10010020  

 

NURS 6512 Assignment 2 Week 3 Digital Clinical Experience (DCE) Health History Assessment IN
NURS 6512 Assignment 2 Week 3 Digital Clinical Experience (DCE) Health History Assessment IN

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A Sample Answer 2 For the Assignment: NURS 6512 Assignment 2 Week 3: Digital Clinical Experience (DCE) Health History Assessment IN

Title: NURS 6512 Assignment 2 Week 3: Digital Clinical Experience (DCE) Health History Assessment IN

Chief Complaint (CC): “I got a 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!”

History of Present Illness (HPI): Ms. Jones claimed that one week ago, she was walking on stairs outside when she tripped and fell, causing her right ankle to twist and the ball of her foot to scrape. She went to the emergency room of the nearby hospital, where she received negative results from the x-rays and was given tramadol for the pain she was experiencing. She has been cleaning the wound twice. She has been treating the wound with an antibiotic medication and bandaging it. She adds that the pain and swelling in her ankle have subsided, but that the bottom of her foot is becoming increasingly uncomfortable. She describes the pain as throbbing and sharp when she is forced to bear weights. She reports that her ankle “ached” but it is better now. After taking the most recent dose of tramadol, the level of pain has decreased to a 7 out of 10. The degree of pain when bearing weight is a 9. She says that the ball of foot has become swelled and more red over the previous two days and that yesterday, she noticed discharge pouring from the wound. She also says that the swelling has gotten worse. She claims that there is no smell coming from the wound. Her shoes appear to be too small. She has been seen wearing shoes that are without laces. Last night, she reported a temperature of 102. She denies recent illness. An increased appetite is reported alongside with an accidental weight loss of ten pounds that occurred over the course of the month. Denies making any changes to their diet or amount of physical activity.

Medications: Acetaminophen 500 to 1000 mg PO as needed (headaches). Ibuprofen 600 mg PO twice daily as needed (menstrual cramps). Tramadol 50 mg PO BID prn (foot pain). Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (Wheezing while neat cats, most recent administration: three days ago)

 

Allergies: Rash caused by penicillin, Allergic to cats and dust but not food or latex sensitivities. She claims that being among allergens causes her to experience runny nose, itchy and swollen eyes, and an increase in the severity of her asthma symptoms.

 

Past Medical History (PMH): At the age of 2 and a half, the asthma was identified. When she is in an environment with cats or dust, she utilizes the albuterol inhaler that she carries with her. Two of three times a week, she makes use of her inhaler. Three days ago, she was around cats, and she had to use her inhaler once to get some respite from the symptoms that were bothering her. Her last asthma related hospitalization was when she was in high-school. Never had an intubation. Diabetes type 2 was discovered at the age of 24. She had been taking Metformin in the past but stopped doing so three years ago, citing the fact that the drugs caused her to have gas and that “it was stressful taking pills and testing my sugar”. She does not keep an eye on her sugar levels. In the hospital’s emergency room, the patient’s sugar levels were high the week before last. No surgeries. Hematologic: Acne has been a problem for her ever since she hit adolescence and she also gets bumps on the backs of her arms if her skin is dry. Complains of a darkening of the skin on her neck as well as an increase in the hair on her face and body. She has noted that she has a few moles, but no noticeable alterations to her hair or nails.

 

Past Surgical History (PSH): No history of past surgery.

Sexual/Reproductive History: Menarche, age 11. First sexual experience at the age of 18, which encounters were with men, and the individual identifies as straight. Never pregnant. It’s been three weeks since her last menstruation. During the last year, her menstrual period has been quite erratic, occurring every 4-6 weeks and she has had heavy bleeding that lasts 9-10 days. She does not have a partner currently. She used oral contraceptives when she was younger. She claims that she did not use condoms when she was sexually active. Never had an HIV/AIDS test done. No record of previous sexually transmitted infections or signs of STIs. When she was last teste, four years have elapsed.

 

Personal/Social History: Never married and does not have any children. Since the age of 20, has lived on her own, and since her father passed away a year ago, they now share a home with their mother and a sister in a single family dwelling in order to support the family. Currently working as a supervisor at Mid-American Copy and Ship for a total of 32 hours per week. She was just elevated to the position of shift supervisor, which she thoroughly enjoys. She attends school on a part-time basis and is currently in her final semester of work toward obtaining a bachelor’s degree in accounting. She has her sights set on becoming an accountant for the company she currently works for. She is well off as she owns a car, a cellphone and a computer. Even though she is covered by the employer’s basic health insurance, she avoids seeking medical attention because of the out-of-pocket expenses involved. She takes pleasure in socializing with her friends, going to Bible study, being active in the ministry of her church and dancing. Tina has a solid family and social support structure and she is also involved in her local church community. She describes feeling stressed as a result of the death of her father, as well as the responsibilities of her job and education and her financial situation. She states that coping with the stress has been easy because of her family and the church. No tobacco usage. Cannabis use on an irregular basis between the ages of 15 and 21. She denies ever having used cocaine, methamphetamines, or heroine. Utilizes alcoholic beverages “when out with pals, two or three times a month.” and claims to consume no more than three drinks throughout each occasion. She consumes four beverages containing caffeine and diet soda daily. No foreign travel. No pets. She is not in an intimate relationship currently but she completed a significant monogamous relationship that lasted for three years two years ago. It is in her future intentions to start a family by getting married and having children.

 

Health Maintenance: The most recent Pap smear was performed in 2014. The last eye exam was conducted when she was a child. The last time she had a dental exam was a couple of years ago. PPD test was negative less than two years ago. No workout. 24-hour diet recall: She admits that she skipped her breakfast the day before and that she normally consumes baked good for breakfast, sandwich for lunch and either meatloaf or chicken for dinner. However, she did not have any of these foods yesterday. Her munchies are either usually either pretzels of French fries.

 

Immunization History: Regarding immunizations, a tetanus booster shot was administered during the past year; however, a flu shot and vaccine against human papillovirus were not given nor received. She states that she feels that she is up to date on all of her childhood vaccines and that she received the meningococcal vaccine while she was in college. Safety: She does not ride a bike, possesses smoke alarms at home, and always puts on seatbelt whilst driving. Does not use sunscreen. The home has firearms that once belonged to her father and are currently secured in the room used by her parents.

 

 

Significant Family History: The mother is 50 years old and has hypertension and high cholesterol. Father died in a car accident a year ago at the age of 58; he has hypertension, high cholesterol, and type 2 diabetes. Brother (Michael, age 25), suffers from obesity Sister (Brittany, age 14) struggles with asthma Grandmother on the maternal side passed away at the age of 73 as a result of stroke; she had a history of hypertension and excessive cholesterol. Grandfather on the maternal side passed away at the age of 78 as a result of a stroke; he had a history of hypertension and excessive cholesterol. Grandmother on the father’s side is still alive and has hypertension despite being 82 years old. Grandfather on the father’s side passed away at the age of 65 from colon cancer, family history of type 2 diabetes. Negative for mental illness other malignancies, unexpected death, kidney disease, sickle cell anemia, and thyroid disorders. An uncle on the father’s side had a problem with alcoholism.

 

Review of Systems

 

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

            HEENT:

HEAD: The patient’s head is round, symmetrical, and normocephalic; palpation reveals no nodules, masses, or depressions.

EYES: The bulbar conjunctiva was translucent with few capillaries obvious, and there is no edema or tears in the lacrimal gland. However, the patient’s vision is blurry at the moment. Eye lashes appeared to be uniformly distributed. However, the patient’s eyesight is blurry at the moment. During the test of the additional ocular muscle, both eyes moved in sync and aligned themselves parallel to one another.

EAR: The auricle membranes are spotless and are the same color as the skin on the face.

NOSE: The nose seemed straight, symmetrical, and of a single color.

THROAT: The patient denies having any pain, there being any swelling present, and having any trouble swallowing.

Neck: The patient demonstrated synchronized smooth head movement without any signs of discomfort, indicating that the neck muscles are of comparable size.

            Breasts: Patient shows no signs of pain or discomfort.

            Respiratory: The patient has a history of asthma but claims they are not having any respiratory problems. The breathing sounds were regular, and there was no evidence of discomfort

            Cardiovascular/Peripheral Vascular:  The patient states that they are not experiencing any chest pain and that they have no history of hypertension. The patient’s blood pressure is on the cusp of being dangerous. Only experiences chest pressure when she is having trouble breathing, which is otherwise painless.

            Gastrointestinal: The patient reports no discomfort in the abdomen region, and all four quadrants exhibited positive bowel sounds.

 

            Genitourinary: Denies that urinating causes any discomfort

            Musculoskeletal: The patient is experiencing discomfort in their foot

 

            Psychiatric: Denied any history of previous mental health issues.

            Neurological: Patient is alert, oriented x3

            Skin: On the foot, there was a skin break that measured approximately 2 centimeters by 1.5 centimeters and was 2.5 millimeters deep. It was draining pus. Her hands and feet each have skin that is parched and cracked.

            Hematologic: Rejects that they have any blood disorders.

            Endocrine: The patient’s blood glucose level is 238 mg/dl and they have a history of diabetes.

In providing the best care for patients, healthcare providers must display cultural competence and sensitivity. In the article by Sharifi, Adib-Hajbeghery and Najafi (2019), I found a concept to be quite interesting. The article discussed that providers cannot always be 100% on their cultural competence, as cultural aspects are always changing. What is important is that providers do show the ability to adapt and work through the cultural instances presented to them in a positive way, creating and maintaining a positive provider-patient relationship with those cared for.

Culturally competent health care involves providing the same avenues of non-judgmental healthcare for everyone of different cultural and socio-economic backgrounds (Lipovec Čebron & Huber, 2021). In the case study of John Green, several areas are presented where the provider must incorporate cultural awareness. He is a transitioned female to male, within the last two years. Currently, he is unemployed with minimal recent health care. His lifestyle includes use of tobacco (cigarettes, 2 packs per day x 10 years), and moderate marijuana use. Other sensitive areas of discussion includes being HIV positive as well as a diagnosis of depression.

Although all areas of the patient’s background can present as sensitive topics, two stick out to me, being a transitioned female to male as well as being HIV positive. As a provider, it is imperative to keep the patient’s best interest in mind in a non- judgmental manner. Being a transgendered individual, and coming out as one, has become more and more “accepted” over the recent years. In being a provider of an individual identifying as transgender, a safe, caring, accepting environment must be established right away. Unfortunately, these individuals may not have this environment outside healthcare, and without it they may choose to stop visiting the doctor leading to potential complications. Providers must recognize and become familiar with the patient’s wishes as far as name and pronouns. Providers must also recognize any gender dysphoria or other mental health concerns related to the transition (Klein, Paradise, & Goodwin, 2018). In establishing a good rapport with the patient, the most optimal treatment plans can be sought out as a whole.

Another sensitive topic area is the patient’s diagnosis of HIV. HIV is such a stigmatized and stereo-typical illness that becomes difficult for people to discuss. As a clinician, establishing a caring, helpful attitude is crucial. The better the relationship, the less reluctant the patient will be to stop treatment and ‘risky behaviors’. It is important to allow the patient to be active in the treatment planning as well as allowing them the ability to ask questions with honest, thought-out answers (Centers for Disease Control and Prevention, 2019).

 

Targeted Health Questions

  1. Explain to me your sexual practices? Do you participate in safe sex?
  2. What is your preference in sexual partner? Are you currently sexually active? With how many partners are you sexually active with?
  3. Are you seeking out treatment for your depression? Have you ever taken any medication for it? Do you feel that you are safe?
  4. Are you interested in smoking cessation? How long have you used marijuana? Do you use alcohol? If so, how often and how much?
  5. Do you have a supportive home environment? Do you belong to any support groups?

 

References:

Centers for Disease Control and Prevention. (2019). Talking to your patients. Centers for Disease Control and Prevention. Retrieved December 7, 2022, from https://www.cdc.gov/hiv/clinicians/treatment/patient-provider.html

Klein, D. A., Paradise, S. L., & Goodwin, E. T. (2018). Caring for Transgender and Gender-Diverse Persons: What Clinicians Should Know. American family physician98(11), 645–653.

Sharifi, N., Adib-Hajbaghery, M., & Najafi, M. (2019). Cultural competence in nursing: A concept analysis. International Journal of Nursing Studies99, 103386. https://doi.org/10.1016/j.ijnurstu.2019.103386

Lipovec Čebron, U., & Huber, I. (2021). The Evaluation of Cultural Competence in Healthcare. AS: Andragoška Spoznanja27(2). https://doi.org/10.4312/as/10185

Rubric Detail 

Select Grid View or List View to change the rubric’s layout.

 

Content

Name: NURS_6512_Week_4_DCE_Assignment_2_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.

Points Range: 56 (56%) – 60 (60%)

DCE score>93

Points Range: 51 (51%) – 55 (55%)

DCE Score 86-92

Points Range: 46 (46%) – 50 (50%)

DCE Score 80-85

Points Range: 0 (0%) – 45 (45%)

DCE Score <79

No DCE completed.

Subjective Documentation in Provider Notes

Subjective narrative documentation in Provider Notes 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.

Points Range: 36 (36%) – 40 (40%)

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).

Points Range: 31 (31%) – 35 (35%)

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).

Points Range: 26 (26%) – 30 (30%)

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).

Points Range: 0 (0%) – 25 (25%)

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.

Total Points: 100

Name: NURS_6512_Week_4_DCE_Assignment_2_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.

Click here to ORDER an A++ paper from our Verified MASTERS and DOCTORATE WRITERS: NURS 6512 Assignment 2 Week 3: Digital Clinical Experience (DCE) Health History Assessment IN

NURS 6512 Assignment 2 Week 3: Digital Clinical Experience (DCE) Health History Assessment IN Grading Rubric

Performance Category 100% or highest level of performance

100%

16 points

Very good or high level of performance

88%

14 points

Acceptable level of performance

81%

13 points

Inadequate demonstration of expectations

68%

11 points

Deficient level of performance

56%

9 points

 

Failing level

of performance

55% or less

0 points

 Total Points Possible= 50           16 Points    14 Points 13 Points        11 Points           9 Points          0 Points
Scholarliness

Demonstrates achievement of scholarly inquiry for professional and academic topics.

Presentation of information was exceptional and included all of the following elements:

  • Provides evidence of scholarly inquiry relevant to required TD topic(s).
  • Presents specific information from scholarly sources to develop a comprehensive presentation of facts.
  • Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.*
  • Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.
Presentation of information was good, but was superficial in places and included all of the following elements:

  • Provides evidence of scholarly inquiry relevant to required TD topic(s).
  • Presents specific information from scholarly sources to develop a comprehensive presentation of facts.
  • Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.*
  • Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.
Presentation of information was minimally demonstrated in all of the following elements:

  • Provides evidence of scholarly inquiry relevant to required TD topic(s).
  • Presents specific information from scholarly sources to develop a comprehensive presentation of facts.
  • Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.*
  • Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.
 

Presentation of information is unsatisfactory in one of the following elements:

  • Provides evidence of scholarly inquiry relevant to required TD topic(s).
  • Presents specific information from scholarly sources to develop a comprehensive presentation of facts.
  • Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.*
  • Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.
 

Presentation of information is unsatisfactory in two of the following elements:

  • Provides evidence of scholarly inquiry relevant to required TD topic(s).
  • Presents specific information from scholarly sources to develop a comprehensive presentation of facts.
  • Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.*
  • Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.
Presentation of information is unsatisfactory in three or more of the following elements

  • Provides evidence of scholarly inquiry relevant to required TD topic(s).
  • Presents specific information from scholarly sources to develop a comprehensive presentation of facts.
  • Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.*
  • Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information
 16 Points  14 Points  13 Points 11 Points 9 Points  0 Points
Application of Course Knowledge

Demonstrate the ability to analyze and apply principles, knowledge and information learned in the outside readings and relate them to real-life professional situations

Presentation of information was exceptional and included all of the following elements:

  • Applies principles, knowledge and information from scholarly resources to the required topic.
  • Applies facts, principles or concepts learned from scholarly resources to a professional experience.
  • Application of information is comprehensive and specific to the required topic.
Presentation of information was good, but was superficial in places and included all of the following elements:

  • Applies principles, knowledge and information from scholarly resources to the required topic.
  • Applies facts, principles or concepts learned from scholarly resources to a professional experience.
  • Application of information is comprehensive and specific to the required topic.
Presentation of information was minimally demonstrated in the all of the following elements:

  • Applies principles, knowledge and information from scholarly resources to the required topic.
  • Applies facts, principles or concepts learned from scholarly resources to a professional experience.
  • Application of information is comprehensive and specific to the required topic.
Presentation of information is unsatisfactory in one of the following elements:

  • Applies principles, knowledge and information from scholarly resources to the required topic.
  • Applies facts, principles or concepts learned from and scholarly resources to a professional experience.
  • Application of information is comprehensive and specific to the required topic.
Presentation of information is unsatisfactory in two of the following elements:

  • Applies principles, knowledge and information from scholarly resources to the required topic.
  • Applies facts, principles or concepts learned from scholarly resources to a professional experience.
  • Application of information is comprehensive and specific to the required topic.
Presentation of information is unsatisfactory in three of the following elements

  • Applies principles, knowledge and information and scholarly resources to the required topic.
  • Applies facts, principles or concepts learned scholarly resources to a professional experience.
  • Application of information is comprehensive and specific to the required topic.
   10 Points 9 Points  6 Points  0 Points
Interactive Dialogue

Initial post should be a minimum of 300 words (references do not count toward word count)

The peer and instructor responses must be a minimum of 150 words each (references do not count toward word count)

Responses are substantive and relate to the topic.

Demonstrated all of the following:

  • Initial post must be a minimum of 300 words.
  • The peer and instructor responses must be a minimum of 150 words each.
  • Responses are substantive
  • Responses are related to the topic of discussion.
Demonstrated 3 of the following:

  • Initial post must be a minimum of 300 words.
  • The peer and instructor responses must be a minimum of 150 words each.
  • Responses are substantive
  • Responses are related to the topic of discussion.
Demonstrated 2 of the following:

  • Initial post must be a minimum of 300 words.
  • The peer and instructor responses must be a minimum of 150 words each.
  • Responses are substantive
  • Responses are related to the topic of discussion.
Demonstrated 1 or less of the following:

  • Initial post must be a minimum of 300 words.
  • The peer and instructor responses must be a minimum of 150 words each.
  • Responses are substantive
  • Responses are related to the topic of discussion.
  8 Points 7 Points  6 Points         5 Points          4 Points  0 Points
Grammar, Syntax, APA

Points deducted for improper grammar, syntax and APA style of writing.

The source of information is the APA Manual 6th Edition

Error is defined to be a unique APA error. Same type of error is only counted as one error.

The following was present:

  • 0-3 errors in APA format

AND

  • Responses have 0-3 grammatical, spelling or punctuation errors

AND

  • Writing style is generally clear, focused on topic,and facilitates communication.
The following was present:

  • 4-6 errors in APA format.

AND/OR

  • Responses have 4-5 grammatical, spelling or punctuation errors

AND/OR

  • Writing style is somewhat focused on topic.
The following was present:

  • 7-9 errors in APA format.

AND/OR

  • Responses have 6-7 grammatical, spelling or punctuation errors

AND/OR

  • Writing style is slightly focused on topic making discussion difficult to understand.
 

The following was present:

  • 10- 12 errors in APA format

AND/OR

  • Responses have 8-9 grammatical, spelling and punctuation errors

AND/OR

  • Writing style is not focused on topic, making discussion difficult to understand.
 

The following was present:

  • 13 – 15 errors in APA format

AND/OR

  • Responses have 8-10 grammatical, spelling or punctuation errors

AND/OR

  • Writing style is not focused on topic, making discussion difficult to understand.

AND/OR

  • The student continues to make repeated mistakes in any of the above areas after written correction by the instructor.
The following was present:

  • 16 to greater errors in APA format.

AND/OR

  • Responses have more than 10 grammatical, spelling or punctuation errors.

AND/OR

  • Writing style does not facilitate communication
  0 Points Deducted 5 Points Lost
Participation

Requirements

Demonstrated the following:

  • Initial, peer, and faculty postings were made on 3 separate days
Failed to demonstrate the following:

  • Initial, peer, and faculty postings were made on 3 separate days
  0 Points Lost 5 Points Lost
Due Date Requirements Demonstrated all of the following:

  • The initial posting to the graded threaded discussion topic is posted within the course no later than Wednesday, 11:59 pm MT.

A minimum of one peer and one instructor responses are to be posted within the course no later than Sunday, 11:59 pm MT.

Demonstrates one or less of the following.

  • The initial posting to the graded threaded discussion topic is posted within the course no later than Wednesday, 11:59 pm MT.

A minimum of one peer and one instructor responses are to be posted within the course no later than Sunday, 11:59 pm MT.

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