Assignment 2: Digital Clinical Experience (DCE): Health History Assessment NURS 6512N

Assignment 2: Digital Clinical Experience (DCE): Health History Assessment NURS 6512N

Assignment 2: Digital Clinical Experience (DCE): Health History Assessment NURS 6512N

Assignment 2: Digital Clinical Experience
(DCE): Health History Assessment
A comprehensive health history is essential to providing quality care for patients across
the lifespan, as it helps to properly identify health risks, diagnose patients, and develop
individualized treatment plans. To effectively collect these heath histories, you must not
only have strong communication skills, but also the ability to quickly establish trust and
confidence with your patients. For this DCE Assignment, you begin building your
communication and assessment skills as you collect a health history from a volunteer
"patient."
Photo Credit: Sam Edwards / Caiaimage / Getty Images
To Prepare
 Review this week’s Learning Resources as well as the Taking a Health History media
program, and consider how you might incorporate these strategies. Download and
review the Student Checklist: Health History Guide and the History Subjective Data
Checklist, provided in this week's Learning Resources, to guide you through the
necessary components of the assessment.

 Access and login to Shadow Health using the link in the left-hand navigation of the
Blackboard classroom.
 Review the Shadow Health Student Orientation media program and the Useful Tips and
Tricks document provided in the week’s Learning Resources to guide you through
Shadow Health.
 Review the Week 4 DCE Health History Assessment Rubric, provided in the
Assignment submission area, for details on completing the Assignment.
DCE Health History Assessment:
Complete the following in Shadow Health:
Orientation
 DCE Orientation (15 minutes)
 Conversation Concept Lab (50 minutes)
Health History
 Health History 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 80% or better, but you must take all
attempts by the Week 4 Day 7 deadline.
Submission and Grading Information
No Assignment submission due this week but will be due Day 7, Week 4.
Grading Criteria
To access your rubric:
Week 4 Assignment 2 DCE Rubric

What's Coming Up in Module 3?

Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images
In Module 3, you will examine advanced health assessments using a system focused
approach.
Next week, you will specifically explore how to assess the skin, hair, and nails, as well
as how to evaluate abnormal skin findings while conducting health assessments. You
will also complete your first Lab Assignment: Differential Diagnosis for Skin Conditions
as well as complete your DCE: Health History Assessment in the simulation tool,
Shadow Health.
Week 4 Required Media
Photo Credit: [fergregory]/[iStock / Getty Images Plus]/Getty Images
Next week, you will need to view several videos and animations in Seidel’s Guide to
Physical Examination as well as other media, as required, prior to completing your Lab
Assignment. There are several videos in varied lengths. Please plan ahead to ensure
you have time to view these media programs to complete your Assignment on time.
Next Module

To go to the next module:
Module 3

Learning Resources

Required Readings (click to expand/reduce)
Note: To access this week's required library resources, please click on the
link to the Course Readings List, found in the Course Materials section of
your Syllabus.
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 3, “Examination Techniques and Equipment”
This chapter explains the physical examination techniques of inspection,
palpation, percussion, and auscultation. This chapter also explores special
issues and equipment relevant to the physical exam process.

 Chapter 8, “Growth and Nutrition”
In this chapter, the authors explain examinations for growth, gestational
age, and pubertal development. The authors also differentiate growth
among the organ systems.

 Chapter 5, “Recording Information”  (Previously read in Week 1)
This chapter provides rationale and methods for maintaining clear and
accurate records. The text also explores the legal aspects of patient
records.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Student checklist: Health history guide. In Seidel's guide to
physical examination (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.
Centers for Disease Control and Prevention. (2018). Childhood overweight
and obesity. Retrieved from http://www.cdc.gov/obesity/childhood

This website provides information about overweight and obese children.
Additionally, the website provides basic facts about obesity and strategies
to counteracting obesity.

Chaudhry, M. A. I., & Nisar, A. (2017). Escalating health care cost due to
unnecessary diagnostic testing. Mehran University Research Journal of
Engineering and Technology, (3), 569.

This study explores the escalating healthcare cost due the
unnecessary use of diagnostic testing. Consider the impact of
health insurance coverage in each state and how nursing
professionals must be cognizant when ordering diagnostics for
different individuals.

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 1, “Clinical Reasoning, Evidence-Based Practice, and Symptom
Analysis”

This chapter introduces the diagnostic process, which includes performing
an analysis of the symptoms and then formulating and testing a
hypothesis. The authors discuss how becoming an expert clinician takes
time and practice in developing clinical judgment.

Gibbs , H., & Chapman-Novakofski, K. (2012). Exploring nutrition literacy:
Attention to assessment and the skills clients need. Health, 4(3), 120–124.
This study explores nutrition literacy. The authors examine the
level of attention paid to health literacy among nutrition
professionals and the skills and knowledge needed to
understand nutrition education.

Martin, B. C., Dalton, W. T., Williams, S. L., Slawson, D. L., Dunn, M. S., &
Johns-Wommack, R. (2014). Weight status misperception as related to
selected health risk behaviors among middle school students. Journal of
School Health, 84(2), 116–123. doi:10.1111/josh.12128
Credit Line: Weight status misperception as related to selected health risk behaviors among middle school students by Martin,
B. C., Dalton, W. T., Williams, S. L., Slawson, D. L., Dunn, M. S., & Johns-Wommack, R., in Journal of School Health, Vol.
84/Issue 2. Copyright 2014 by Blackwell Publishing. Reprinted by permission of Blackwell Publishing via the Copyright
Clearance Center.

Noble, H., & Smith, J. (2015) Issues of validity and reliability in qualitative
research . Evidence Based Nursing, 18(2), pp. 34–35.

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. (2011). History subjective 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.

This History Subjective Data Checklist was published as a companion to
Seidel’s Guide to Physical Examination (8th ed.) by Ball, J. W., Dains, J.
E., & Flynn, J.A. Copyright Elsevier (2015). From
https://evolve.elsevier.com
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.).
Philadelphia, PA: F. A. Davis.
 Chapter 2, "The Comprehensive History and Physical Exam" (Previously
read in Week 1)
 Chapter 5, "Pediatric Preventative Care Visits" (pp. 91 101)
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: Shadow Health Nursing Documentation Tutorial (Word
document)
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.
Optional Resource
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s
diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.

 Chapter 3, "The Physical Screening Examination"

 Chapter 17, "Principles of Diagnostic Testing"
 Chapter 18, "Common Laboratory Tests"
Required Media (click to expand/reduce)

Taking a Health History

How do nurses gather information and assess a patient’s health?
Consider the importance of conducting an in-depth health assessment
interview and the strategies you might use as you watch. (16m)
Accessible player

Rubric Detail

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

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.
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.
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.
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).
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).
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).
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.

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