(Solution) NR509 Week 1: Shadow Health Assessment Assignment

Assignment

Step One: Complete the Shadow Health Orientation

Step Two: Complete Conversation Lab

Step Three: Complete Health History Assignment

Step Four: Document your findings on the   downloador the  

Step Five: Upload the Lab Pass and completed SOAP Note as separate documents to the same assignment tab in the gradebook.

Requirements

NOTE: Before initiating any activity in Shadow Health, complete the required course weekly readings and lessons as well as review the introduction and pre-brief

On the Shadow Health Platform:

  1. Complete the Shadow Health Conversation Concept Lab prior to beginning the graded assignment.
  2. Gather subjective and objective data by completing a comprehensive health history and brief physical examination for the assessment assignment.
  3. Critically appraise the findings as normal or abnormal.
  4. Based on the interview and brief physical assessment, create a problem list.
  5. Complete the post activity assessment questions for each assignment.
  6. Complete all reflection questions following each physical assessment assignment.
  7. Digital Clinical Experience (DCE) scores do not round up. For example, a DCE score of 92.99 is a 92, not a 93.
  8. You have a maximum of two (2) attempts per Shadow Health assignment to improve your performance. However, you may elect not to repeat any assignment. NOTE: If you repeat an attempt, ONLY the second attempt will be graded, regardless of the DCE score. Please refer to the grading rubric categories for details.
  9. Download the Lab Pass for the final attempt on the assignment (see number 8).

On the Canvas Platform:

  1. Summarize, organize, and appropriately document findings using correct professional terminology on the SOAP Note Template.
  2. Document a comprehensive problem list based upon the history and physical examination findings on the SOAP Note Template.
  3. Provide rationales and citations for diagnoses and interventions for the brief treatment plan.
  4. Include at least one scholarly source to support diagnoses and treatment interventions with rationales and references on the SOAP note. Only scholarly sources are acceptable for citation and reference in this course. These include peer-reviewed publications, government reports, or sources written by a professional or scholar in the field. The textbooks and lessons are NOT considered to be outside scholarly sources. For the threaded discussions and reflection posts, reputable internet sources such as websites by government agencies (URL ends in .gov) and respected organizations (often ends in .org) can be counted as scholarly sources. The best outside scholarly source to use is a peer-reviewed nursing journal.  You are encouraged to use the Chamberlain library and search one of the available databases for a peer-reviewed journal article.  The following sources should not be used: Wikipedia, Wikis, or blogs.  These websites are not considered scholarly as anyone can add to these. Please be aware that .com websites can vary in scholarship and quality.  For example, the American Heart Association is a .com site with scholarship and quality. Each student is responsible for determining the scholarship and quality of any .com site.  Ask your instructor before using any site if you are unsure. Points will be deducted from the rubric if the site does not demonstrate scholarship or quality. Current outside scholarly sources must be published with the last 5 years.  Instructor permission must be obtained BEFORE the assignment is due if using a source that is older than 5 years.
  5. Upload the Lab Pass to the appropriate assignment area in Canvas Grades

Solution: 

S:Subjective

Information the patient or patient representative told you

SOAP Note Template

 

 

Initials: T.J. Age: 28 Gender:Female
Height Weight BP HR RR Temp SPO2 Pain Rating Allergies (and reaction)
170cm 90kg 142/82 86 19 101.1 99 7/10 Medication: PCN

Food: None

Environment: Cats
 History of Present Illness (HPI)
Chief Complaint (CC) Right foot pain fall at home CC is a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.  Sometimes a patient has more than one complaint.  For example: If the patient presents with cough and sore throat, identify which is the CC  and which may be an associated symptom
Onset 7 days ago
Location Right foot, heel, radiates to the ankle
Duration Constant pain last few days
Characteristics Throbbing pain
Aggravating Factors Pain is worst when bearing weight on foot
Relieving Factors Elevating extremity
Treatment Tramadol for pain
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

 

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