NURS-6512 Week 9: Assessment of Cognition and the Neurologic System Papers

NURS-6512 Week 9: Assessment of Cognition and the Neurologic System Papers NURS-6512 Week 9: Assessment of Cognition and the Neurologic System Papers A 63-year-old woman comes to your office because she’s been forgetting things…a young mother comes in concerned because her baby fails to make eye contact and is unresponsive to touch…a teenager comes in and a parent complains that the teen obsessively washes his hands. NURS-6512 Week 9: Assessment of Cognition and the Neurologic System Papers An array of neurological conditions could be causing the above symptoms. When assessing the neurologic system, it is vital to formulate an accurate diagnosis as early as possible to prevent continued damage and deterioration of a patient’s quality of life. This week, you will explore methods for assessing the cognition and the neurologic system. ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS Learning Objectives Students will: Evaluate abnormal neurological symptoms Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for cognition and the neurologic system Assess health conditions based on a head-to-toe physical examination Learning Resources – NURS-6512 Week 9: Assessment of Cognition and the Neurologic System Papers Required Readings (click to expand/reduce) Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. Chapter 7, “Mental Status” This chapter revolves around the mental status evaluation of an individual’s overall cognitive state. The chapter includes a list of mental abnormalities and their symptoms. ·Chapter 23, “Neurologic System” The authors of this chapter explore the anatomy and physiology of the neurologic system. The authors also describe neurological examinations and potential findings. Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center. Chapter 4, “Affective Changes” This chapter outlines how to identify the potential cause of affective changes in a patient. The authors provide a suggested approach to the evaluation of this type of change, and they include specific tools that can be used as part of the diagnosis. Chapter 9, “Confusion in Older Adults” This chapter focuses on causes of confusion in older adults, with an emphasis on dementia. The authors include suggested questions for taking a focused history as well as what to look for in a physical examination. Chapter 13, “Dizziness” Dizziness can be a symptom of many underlying conditions. This chapter outlines the questions to ask a patient in taking a focused history and different tests to use in a physical examination. Chapter 19, “Headache” The focus of this chapter is the identification of the causes of headaches. The first step is to ensure that the headache is not a life-threatening condition. The authors give suggestions for taking a thorough history and performing a physical exam. Chapter 31, “Sleep Problems” In this chapter, the authors highlight the main causes of sleep problems. They also provide possible questions to use in taking the patient’s history, things to look for when performing a physical exam, and possible laboratory and diagnostic studies that might be useful in making the diagnosis. NURS-6512 Week 9: Assessment of Cognition and the Neurologic System Papers Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis. Chapter 2, “The Comprehensive History and Physical Exam” (“Cranial Nerves and Their Function” and “Grading Reflexes”) (Previously read in Weeks 1, 2, 3, and 5) Note: Download the Physical Examination Objective Data Checklist to use as you complete the Comprehensive (Head-to-Toe) Physical Assessment assignment. Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical examination objective data checklist. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Mosby’s Guide to Physical Examination, 7th Edition by Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2011 by Elsevier. Reprinted by permission of Elsevier via the Copyright Clearance Center. Note: Download and review the Student Checklists and Key Points to use during your practice neurological examination. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Neurologic system: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Neurologic system: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Mental status: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center. Bearden , S. T., & Nay, L. B. (2011). Utility of EEG in differential diagnosis of adults with unexplained acute alteration of mental status. American Journal of Electroneurodiagnostic Technology, 51 (2), 92–104. This article reviews the use of electrocenographs (EEG) to assist in differential diagnoses. The authors provide differential diagnostic scenarios in which the EEG was useful. Athilingam, P ., Visovsky, C., & Elliott, A. F. (2015). Cognitive screening in persons with chronic diseases in primary care: Challenges and recommendations for practice. American Journal of Alzheimer’s Disease & Other Dementias, 30 (6), 547–558. doi:10.1177/1533317515577127 Sinclair , A. J., Gadsby, R., Hillson, R., Forbes, A., & Bayer, A. J. (2013). Brief report: Use of the Mini-Cog as a screening tool for cognitive impairment in diabetes in primary care. Diabetes Research and Clinical Practice, 100 (1), e23–e25. doi:10.1016/j.diabres.2013.01.001 Roalf, D. R., Moberg, P. J., Xei, S. X., Wolk, D. A., Moelter, S. T., & Arnold, S. E. (2013). Comparative accuracies of two common screening instruments for classification of Alzheimer’s disease, mild cognitive impairment, and healthy aging. Alzheimer’s & Dementia, 9 (5), 529–537. doi:10.1016/j.jalz.2012.10.001. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4036230/ NURS-6512 Week 9: Assessment of Cognition and the Neurologic System Papers Shadow Health Support and Orientation Resources Use the following resources to guide you through your Shadow Health orientation as well as other support resources: Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file]. Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY Shadow Health. (n.d.). Shadow Health help desk. Retrieved from https://support.shadowhealth.com/hc/en-us Document : Shadow Health. (2014). Useful tips and tricks (Version 2) (PDF) Document : Student Acknowledgement Form (Word document) Note : You will sign and date this form each time you complete your DCE Assignment in Shadow Health to acknowledge your commitment to Walden University’s Code of Conduct. Document : DCE (Shadow Health) Documentation Template for Comprehensive (Head-to-Toe) Physical Assessment (Word document) Use this template to complete your Assignment 3 for this week. Optional Resources – NURS-6512 Week 9: Assessment of Cognition and the Neurologic System Papers LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical. Chapter 14, “The Neurologic Examination” (pp. 683–765) This chapter provides an overview of the nervous system. The authors also explain the basics of neurological exams. Chapter 15, “Mental Status, Psychiatric, and Social Evaluations” (pp. 766–786) In this chapter, the authors provide a list of common psychiatric syndromes. The authors also explain the mental, psychiatric, and social evaluation process. Mahlknecht, P., Hotter, A., Hussl, A., Esterhammer, R., Schockey, M., & Seppi, K. (2010). Significance of MRI in diagnosis and differential diagnosis of Parkinson’s disease. Neurodegenerative Diseases, 7 (5), 300–318. Required Media (click to expand/reduce) Online media for Seidel’s Guide to Physical Examination It is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination . Focus on the videos and animations in Chapters 7 and 23 that relate to the assessment of cognition and the neurologic system. Refer to the Week 4 Learning Resources area for access instructions on https://evolve.elsevier.com/ ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS Assignment 1: Case Study Assignment: Assessing Neurological Symptoms Photo Credit: Getty Images/iStockphoto Imagine not being able to form new memories. This is the reality patients with anterograde amnesia face. Although this form of amnesia is rare, it can result from severe brain trauma. Anterograde amnesia demonstrates just how impactful brain disorders can be to a patient’s quality of living. Accurately assessing neurological symptoms is a complex process that involves the analysis of many factors. In this Case Study Assignment, you will consider case studies that describe abnormal findings in patients seen in a clinical setting. NURS-6512 Week 9: Assessment of Cognition and the Neurologic System Papers To Prepare By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor. Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case. With regard to the case study you were assigned: Review this week’s Learning Resources, and consider the insights they provide about the case study. Consider what history would be necessary to collect from the patient in the case study you were assigned. Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis? Identify at least five possible conditions that may be considered in a differential diagnosis for the patient. The Case Study Assignment Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each. 1. Week 9 Case Study Assignment This week there are 3 case studies. You are writing and submitting an episodic SOAP note. Be sure to follow the SOAP template and rubric to assure that you are completing the assignment correctly. The assignments for this week are as follows: Case Study #1- Last name A-K 20-year-old male complains of experiencing intermittent headaches. The headaches diffuse all over the head, but the greatest intensity and pressure occurs above the eyes and spreads through the nose, cheekbones, and jaw. Case Study #2- Last name L-R 47-year-old obese female complains of pain in her right wrist, with tingling and numbness in the thumb and index and middle fingers for the past 2 weeks. She has been frustrated because the pain causes her to drop her hair-styling tools Case Study #3- Last name S-Z 33-year-old female comes to your clinic alarmed about sudden “drooping” on the right side of the face that began this morning. She complains of excessive tearing and drooling on her right side as well. 2. Discussion Boards – overall great job with your discussion posts. You are providing additional insight to your peers and incorporating good additional references. When writing your initial post, be sure to follow the SOAP template format. Insert or discuss the information that you would want to have to arrive at your list of differentials. Be specific…ie: when discussing ROM. You need to indicate….FROM of left shoulder, etc… be specific in how you document. Your differentials are all looking good. Be sure to list in reverse chronological order…..most suspected to least suspected. I have been challenging you to also think out of the box with those differentials. Just because we are working on a musculoskeletal unit…..doesn’t mean it is necessarily a musculoskeletal issue. It could me other medical issues, such as in this past week….back pain could be contributed to an abdominal aneurysm or even a kidney infection. The answer may not always be as black and white as you thing. Think outside the box ?? 3. APA Errors For the most part, everyone is doing a very good job with your references being in APA. Some of you…..I am repeatedly reminding you to correct the same problems I am seeing on a weekly basis. It is not ok just to “freelance” and create your own method of citing articles. You must follow the APA 7th edition manual. Please do so…..you are graduate students expected to work at a graduate level. Also, before hitting submit for your weekly post, make sure you have intext citations for everything on your reference list. Your reference list must match what is in your intext citations. By Day 6 of Week 9 Submit your Assignment. Submission and Grading Information To submit your completed Assignment for review and grading, do the following: Please save your Assignment using the naming convention “WK9Assgn1+last name+first initial.(extension)” as the name. Click the Week 9 Assignment 1 Rubric to review the Grading Criteria for the Assignment. Click the Week 9 Assignment 1 link. You will also be able to “View Rubric” for grading criteria from this area. Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK9Assgn1+last name+first initial.(extension)” and click Open . If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database . NURS-6512 Week 9: Assessment of Cognition and the Neurologic System Papers Click on the Submit button to complete your submission. Grading Criteria To access your rubric: Week 9 Assignment 1 Rubric Rubric Detail – NURS-6512 Week 9: Assessment of Cognition and the Neurologic System Papers Select Grid View or List View to change the rubric’s layout. Name: NURS_6512_Week_9_Assignment1_Rubric Grid View List View Excellent Good Fair Poor Using the Episodic/Focused SOAP Template: · Create documentation or an episodic/focused note in SOAP format about the patient in the case study to which you were assigned. · Provide evidence from the literature to support diagnostic tests that would be appropriate for your case. 45 (45%) – 50 (50%) The response clearly, accurately, and thoroughly follows the SOAP format to document the patient in the assigned case study. The response thoroughly and accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study. 39 (39%) – 44 (44%) The response accurately follows the SOAP format to document the patient in the assigned case study. The response accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study. NURS-6512 Week 9: Assessment of Cognition and the Neurologic System Papers 33 (33%) – 38 (38%) The response follows the SOAP format to document the patient in the assigned case study, with some vagueness and inaccuracy. The response provides evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study, with some vagueness or inaccuracy in the evidence selected. 0 (0%) – 32 (32%) The response incompletely and inaccurately follows the SOAP format to document the patient in the assigned case study. The response provides incomplete, inaccurate, and/or missing evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study. · List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each. 30 (30%) – 35 (35%) The response lists five distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study and provides a thorough, accurate, and detailed justification for each of the five conditions selected. 24 (24%) – 29 (29%) The response lists four to five different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the five conditions selected. 18 (18%) – 23 (23%) The response lists three to four possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or some inaccuracy in the conditions and/or justification for each. 0 (0%) – 17 (17%) The response lists three or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected. Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. 5 (5%) – 5 (5%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. NURS-6512 Week 9: Assessment of Cognition and the Neurologic System Papers 4 (4%) – 4 (4%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive. 3 (3%) – 3 (3%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic. 0 (0%) – 2 (2%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided. Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation 5 (5%) – 5 (5%) Uses correct grammar, spelling, and punctuation with no errors. 4 (4%) – 4 (4%) Contains a few (1 or 2) grammar, spelling, and punctuation errors. 3 (3%) – 3 (3%) Contains several (3 or 4) grammar, spelling, and punctuation errors. 0 (0%) – 2 (2%) Contains many (? 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding. Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list. 5 (5%) – 5 (5%) Uses correct APA format with no errors. 4 (4%) – 4 (4%) Contains a few (1 or 2) APA format errors. 3 (3%) – 3 (3%) Contains several (3 or 4) APA format errors. 0 (0%) – 2 (2%) Contains many (? 5) APA format errors. Total Points: 100 Name: NURS_6512_Week_9_Assignment1_Rubric. NURS-6512 Week 9: Assessment of Cognition and the Neurologic System Papers Check Your Assignment Draft for Authenticity To check your Assignment draft for authenticity: Submit your Week 9 Assignment 1 draft and review the originality report. Submit Your Assignment by Day 6 of Week 9 To participate in this Assignment: Week 9 Assignment 1 Assignment 2: Lab Assignment (Optional): Practice Assessment: Neurological Examination Short of opening a patient’s cranium or requesting a brain scan, what can an advanced practice nurse do to determine the cause of neurological symptoms? A multitude of techniques can be used to generate a neurological diagnosis. In preparation for the Comprehensive (Head-to-Toe) Physical Assessment due this week, it is recommended that you practice performing a neurological examination. Note: This is an optional practice physical assessment. To Prepare Arrange an appropriate time and setting with a volunteer “patient” to perform a neurological examination. Download and review the Neurological Checklist provided in this week’s Learning Resources as well as review Seidel’s Guide to Physical Examination online media. The Lab Assignment Perform the neurological examination. Be sure to cover all of the areas listed in the checklist and to use the plexor appropriately. Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment Throughout this course, you were encouraged to practice conducting various physical assessments on multiple areas of the body, ranging from the head to the toes. Each of these assessments, however, was conducted independently of one another. For this DCE Assignment, you connect the knowledge and skills you gained from each individual assessment to perform a comprehensive head-to-toe physical examination in your Digital Clinical Experience. NURS-6512 Week 9: Assessment of Cognition and the Neurologic System Papers Photo Credit: Getty Images/Hero Images 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. DCE Comprehensive Physical Assessment: Complete the following in Shadow Health: Episodic/Focused Note for Comprehensive Physical Assessment of Tina Jones (180 minutes) Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve a total of 80% or better (this includes your DCE and your Documentation Notes), but you must take all attempts by the Week 9 Day 7 deadline. Submission and Grading Information – NURS-6512 Week 9: Assessment of Cognition and the Neurologic System Papers By Day 7 of Week 9 Complete your Comprehensive (Head-to-Toe) Physical Assessment DCE Assignment in Shadow Health via the Shadow Health link in Blackboard. Once you complete your Assignment in Shadow Health, you will need to download your lab pass and upload it to the corresponding Assignment in Blackboard for your faculty review. ( Note: Please save your lab pass as “LastName_FirstName_AssignmentName”.) You can find instructions for downloading your lab pass here: https://link.shadowhealth.com/download-lab-pass Once you submit your Documentation Notes to Shadow Health, make sure to copy and paste the same Documentation Notes into your Assignment submission link below . Download , sign , date , and submit your Student Acknowledgement Form found in the Learning Resources for this week. Note: You must pass this assignment with a minimum score of 80% in order to pass the class. Once submitted, there are not any opportunities to revise or repeat this assignment. Grading Criteria To access your rubric: Week 9 Assignment 3 DCE Rubric Rubric Detail – NURS-6512 Week 9: Assessment of Cognition and the Neurologic System Papers Select Grid View or List View to change the rubric’s layout. Name: NURS_6512_Week_9_DCE_Assignment_3_Rubric. NURS-6512 Week 9: Assessment of Cognition and the Neurologic System Papers 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. NURS-6512 Week 9: Assessment of Cognition and the Neurologic System Papers Grid View List View 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 <79 No 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). or No 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. or No documentation provided. Total Points: 100 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. Submit Your Assignment by Day 7 of Week 9 To submit your Lab Pass: Week 9 Lab Pass To sumit this required part of the Assignment: Week 9 Documentation Notes for Assignment 3 To Submit your S

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