NUR 634 Shadow Health Focused Exam: HEENT Case Study With Patient Tina Jones

Assessment Description

Within the Shadow Health platform, complete the “Focused Exam: HEENT Case Study with Patient Tina Jones” assessment. The estimated average time to complete this assignment is 90 minutes. Please note, this is an average time. Some learners may need more time.

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Refer to the “Advanced Health Assessment Student Handbook” in the Shadow Health platform prior to beginning the assignment to become familiar with the expectations for successful completion.

To complete this assignment:

Perform History and Physical exam for assigned ShadowHealth Case
Create a SOAP Note using the “NUR-634 SOAP Note Outline” in the Class Resources in a Word document. Do NOT document within ShadowHealth.
Upload your “Lab Pass” and SOAP Note Word document to the dropbox.
At least two APRN-approved scholarly references supporting your Assessment/Plan are required.

Upon completion of the assignment, submit the Lab Pass and SOAP note to the assignment dropbox.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are not required to submit this assignment to LopesWrite.

American Association of Colleges of Nursing Core Competencies for Professional Nursing Education

This assignment aligns to AACN Core Competencies 1.1, 1.2, 1.3, 2.1, 2.2, 2.3, 2.4, 2.5, 2.6, 2.8, 4.2, 5.2, 6.3, 9.2.

Shadow Health Focused Exam: HEENT Case Study With Patient Tina Jones – Rubric

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Rubric Criteria

Total16 points

Criterion	1. Unsatisfactory	2. Insufficient	3. Approaching	4. Acceptable	5. Target
Subjective Chief Complaint, HPI, History, Comprehensive ROS as per assignment instructions	0 points Subjective data is not present.	1.2 points Subjective data is incomplete.	1.92 points Subjective data is present with several omissions/errors.	2.16 points Subjective data is present with few omissions/errors.	2.4 points Subjective data is present and error free.
Objective Focused Physical Exam, Diagnostics as per assignment instructions.	0 points Objective data is not present.	1.2 points Objective data is incomplete.	1.92 points Objective data is present with several omissions/errors.	2.16 points Objective data is present with few omissions/errors.	2.4 points Objective data is present and error free.
Assessment Working diagnosis with at least 2 additional differentials, Comprehensive Problem list with ICD-10 codes as per assignment instructions.	0 points Assessment is not present.	1.2 points Assessment is incomplete.	1.92 points Assessment is present with several omissions/errors.	2.16 points Assessment is present with few omissions/errors.	2.4 points Assessment is present and error free.
Plan Diagnostics, nonpharmacologic and pharmacologic therapy, referral(s), education, follow up as per assignment instructions.	0 points Plan is not present. .	1.2 points Plan is incomplete.	1.92 points Plan is present with several omissions/errors.	2.16 points Plan is present with few omissions/errors.	2.4 points Plan is present and error free.
References Two APRN-approved references are utilized to support content and are linked to content with intext citations. Citations are appropriately formatted per most recent APA edition. Non-APRN-approved references are not permitted.	0 points No APRN-approved references utilized.	0.8 points Less than two APRN-approved references utilized or non-APRN-approved references are utilized.	1.28 points Required number of approved references utilized with major errors in format.	1.44 points Required number of approved references utilized with minor errors in format.	1.6 points Required number of approved references utilized without errors in format.
DCE /LabPass Score	0 points DCE score is 0-79.99%.	2.4 points DCE score is 80-84.9%.	3.84 points DCE score is 85-89.9%.	4.32 points DCE score is 90-94.9%.	4.8 points DCE score is 95-100%.

Criterion

1. Unsatisfactory

2. Insufficient

3. Approaching

4. Acceptable

5. Target

Subjective

Chief Complaint, HPI, History, Comprehensive ROS as per assignment instructions

0 points

Subjective data is not present.

1.2 points

Subjective data is incomplete.

1.92 points

Subjective data is present with several omissions/errors.

2.16 points

Subjective data is present with few omissions/errors.

2.4 points

Subjective data is present and error free.

Objective

Focused Physical Exam, Diagnostics as per assignment instructions.

0 points

Objective data is not present.

1.2 points

Objective data is incomplete.

1.92 points

Objective data is present with several omissions/errors.

2.16 points

Objective data is present with few omissions/errors.

2.4 points

Objective data is present and error free.

Assessment

Working diagnosis with at least 2 additional differentials, Comprehensive Problem list with ICD-10 codes as per assignment instructions.

0 points

Assessment is not present.

1.2 points

Assessment is incomplete.

1.92 points

Assessment is present with several omissions/errors.

2.16 points

Assessment is present with few omissions/errors.

2.4 points

Assessment is present and error free.

Plan

Diagnostics, nonpharmacologic and pharmacologic therapy, referral(s), education, follow up as per assignment instructions.

0 points

Plan is not present. .

1.2 points

Plan is incomplete.

1.92 points

Plan is present with several omissions/errors.

2.16 points

Plan is present with few omissions/errors.

2.4 points

Plan is present and error free.

References

Two APRN-approved references are utilized to support content and are linked to content with intext citations. Citations are appropriately formatted per most recent APA edition. Non-APRN-approved references are not permitted.

0 points

No APRN-approved references utilized.

0.8 points

Less than two APRN-approved references utilized or non-APRN-approved references are utilized.

1.28 points

Required number of approved references utilized with major errors in format.

1.44 points

Required number of approved references utilized with minor errors in format.

1.6 points

Required number of approved references utilized without errors in format.

DCE /LabPass Score

0 points

DCE score is 0-79.99%.

2.4 points

DCE score is 80-84.9%.

3.84 points

DCE score is 85-89.9%.

4.32 points

DCE score is 90-94.9%.

4.8 points

DCE score is 95-100%.