Shadow health Tina Jones-Guide to Comprehensive Assessment
Shadow health Tina Jones
Advanced Health
Assessment
Student Handbook
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Contents
Health History ………………………………………………………………………………………………………………………………….. – 4 –
Example SOAP note Documentation …………………………………………………………………………………………………… – 6 –
Self-Reflection …………………………………………………………………………………………………………………………………. – 8 –
HEENT …………………………………………………………………………………………………………………………………………..- 10 –
Respiratory ……………………………………………………………………………………………………………………………………..- 11 –
Cardiovascular ………………………………………………………………………………………………………………………………..- 12 –
Abdominal ………………………………………………………………………………………………………………………………………- 13 –
Musculoskeletal ……………………………………………………………………………………………………………………………….- 14 –
Neurological ……………………………………………………………………………………………………………………………………- 15 –
Mental Health ………………………………………………………………………………………………………………………………….- 16 –
Focused Exam: Cough ……………………………………………………………………………………………………………………..- 17 –
Focused Exam: Chest Pain ……………………………………………………………………………………………………………….- 18 –
Focused Exam: Abdominal Pain …………………………………………………………………………………………………………- 19 –
Comprehensive Assessment ……………………………………………………………………………………………………………..- 20 –
Welcome!
Shadow Health® understands that you want to learn your core nursing competencies in the most engaging and effective way possible. The Shadow Health Digital Clinical Experience (DCE) provides you with a dynamic, immersive experience designed to enrich classroom instruction through the clinical examination of our Digital Standardized Patients.™ We are committed to providing you with an innovative, intuitive virtual clinical experience that offers comprehensive participation in a safe learning environment.
Health History
As healthcare professionals, the health history helps us compile important information to better care for our patients. You should conduct a thorough patient interview to collect all the necessary information to treat your patient.
Instructions: In the Health History assignment, you will interview your first Digital Standardized Patient, Tina Jones, document her comprehensive health history, and complete post-exam activities. Students spend, on average, two and a half hours on this assignment.
Your goal in this assignment is to conduct a health history that is appropriate for Tina Jones. You will use the details of the patient case and data you gather to make decisions about which questions and follow-up opportunities are necessary. Although Ms. Jones can answer over 100,000 questions, you should only need to ask a fraction of these to obtain a complete health history.
You will be evaluated on your ability to use the patient’s context to construct a health interview that is thorough and relevant for Ms. Jones.
- Ask questions about each relevant topic of a patient interview to collect patient data
- Listen to the patient’s responses for cues that prompt
- Follow-up questions
- Empathy
- Patient education
- Document patient data in the EHR Plan your time:
First Turn In | Allow Reopening | Flexible Turn In |
~150 minutes | ~190 minutes | ~260 minutes |
Getting Started: View this tutorial for guidance on getting started with the Health History Assignment.
Tips for Success: Unlike the Conversation Concept Lab, there are no prompts during your interview, so you should prepare prior to entering Ms. Jones’ room. We suggest taking out your textbook and/or reference materials to remind yourself of what taking a health history entails.
There are essential sections of patient information that your interview will need to uncover. As you learned in the Conversation Concept Lab, there are multiple essential questions for each of these topics:
Chief Complaint
History of Present Illness
Medical History
- Medication
- Allergies
- Immunizations
- Diabetes
- Asthma
- Hypertension
Gynecological and Sexual History
Social History
- Daily Life
- Diet and Nutrition
- Substance Use
Review of Systems
Family History
- 3 Generations
- Inherited Risk Factors
Know all of your qualifying questions for any symptom that may be reported:
- Onset
- Location
- Duration
- Characteristics
- Aggravating/alleviating factors
- Related symptoms
- Treatments tried
Example SOAP note Documentation
Subjective: The “s”, or subjective data portion of your SOAP note should include your chief complaint, HPI, and any relevant medical, family, or history pertaining to the patient’s chief complaint as well as a focused review of systems. This is the information that the patient reports directly to you.
The patient is a 70 year old female complaining of abdominal pain and indigestion. The lessens the pain, but did not improve her pain in the last incident. One a scale of 10, she dull, constant pain is located in the upper right quadrant of her abdomen. It started four days ago and is occasionally also in her right shoulder blade. Nausea accompanies the pain. Eating worsens the pain, making her feel excess gas and bloating. Rolaids normally rates the pain as an 8. PMH – no significant PMH Family Hx – Her brother had his gallbladder removed 2 years ago. Mother died of alzheimer’s, father of heart attack. Social Hx – Married, currently retired after raising her family and working as a homemaker her whole life. She walks 3 times a week for 30 minutes. Rarely drinks and doesn’t smoke. ROS – General decrease in appetite. Fear of eating. Skin rash on feet.
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Objective: The “o” or objective data portion of your SOAP note should include your vital signs, clinical exam, and any blood work or radiology exams that have been done recently. In this portion you want to give a clear clinical picture of what is going on with the patient. This portion of a S.O.A.P note consists of what you, the clinician can observes. It can be measurable.
Vital Signs – BP 125/85, P 70 bpm, R 16 breaths, T 99.1 ̊F The patient is friendly and well groomed. She is not in any obvious distress. HEENT – pupils round reactive to light. No scleroicteris. Moist Mucous membranes. No lymphadenopathy, no thyromegaly, bruits, neck supple. Respiratory – Lungs clear on auscultation. Resonant to percussion. Cardiac – regular rate and rhythm. No murmurs or gallops Abdominal – No surgical scars, no distention. Normal active bowel sounds in all four quadrants. No bruits heard in abdominal aorta, renal arteries, or iliac arteries. Discomfort was felt on light and deep palpation of the right upper quadrant. Liver and spleen are not enlarged. She had no rebound tenderness or guarding. Breast and pelvic exams done by previous primary care physician. Extremities/musculoskeletal – 2+ radial and dorsalis pulses no clubbing or cyanosis or edema. Full range of motion in her shoulders, elbows, hands, hips, knees and ankles without pain tenderness or swelling. No scapular tenderness. Neuro – Cranial Nerves 2 – 12 intact. Strength 5/5 bilateral upper and lower extremities. Deep tendon reflexes 2+ throughout. Romberg normal, gait normal.
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Assessment: In the “a”, or assessment portion, you are going to synthesize the subjective and objective data into a list of prioritized differential diagnosis. The likely diagnosis should be included in this section of the note. The assessment may also include information on various diagnostic tests that may be ordered, such as x-rays, blood work and referrals to other specialist.
1. abdominal pain – presentation suggestive of gallstone disease. Less likely possibilities include hepatitis, gastritis, peptic ulcer disease, and atypical ischemic heart disease. |
Plan: In the “p”, or plan section of your SOAP note, you are going to discuss how you would like to treat your patient. It should include what type of treatments will be given, such as medication, therapies, and surgeries. It may also list long-term treatment plans and recommended changes to lifestyle, as well as short and long term goals for the patient. It should also detail what kind of follow up is necessary.
Workup will include a sonogram of the RUQ and complete blood count and liver chemistries, and an EKG. We will have the patient follow up with results. |
Self-Reflection
In all assignments, remember to complete your Self-Reflection, if your instructor has left this activity available for you to complete.
What is Self-Reflection? Self-reflection enables us to look at our performance – be it on the job, in the classroom, or out on the field – and critique our practice in a systematic and rigorous way. This process enables us to develop a greater sense of self awareness and to create a plan to improve on areas of weakness in our performance.
We gain critical insights from this reflection that help us move from novices to experts in our fields. Self-reflection is proven1 to improve our skills as providers, which leads to better patient outcomes.
How do I begin? As you reflect on your practice, thinking about things that have gone well will help you to understand how you can make this happen more often. Conversely, thinking about things that haven’t gone so well helps you to think about how things could be different in the future. Here are some questions to ask yourself:
- What are you reflecting on?
a.) What assignment did you complete?
b.) How did you do on the assignment?
c.) Did you meet your goal and achieve a score you were happy with?
- How were you thinking and feeling
a.) What were you feeling while completing the assignment?
b.) How do you feel about your score?
- Evaluate
a.) What are the highs and lows of your experience?
b.) Were there any factors that influenced the outcome?
- Analyze
a.) What could I have done differently?
b.) What did I do that was successful that I will continue to do?
c.) What did I do that was unsuccessful that I will discontinue?
- Conclusion
a.) How do I feel about the overall experience?
b.) What have I learned about my practice?
c.) How will this experience change my nursing practice?
d.) Are there any factors in a real life scenario that may be different than this virtual environment that may prevent me from reaching my goal that I can anticipate?
—————Gustafsson, C., and Fagerberg, I. (2004), Reflection, the way to professional development? Journal of Clinical Nursing, 13: 271-280
Excerpt from an Excellent Self-
Reflection |
Excerpt from a Satisfactory Self-
Reflection |
Excerpt from an Unsatisfactory Self-Reflection |
I asked Mrs. Smith about her health history and tried to find more in- formation about her low back pain, cough, and frequent urinary tract infections. OLDCARTS helped guide me through the 7 dimensions of her complaints.
I assumed that if I went through OLDCARTS I would capture all of the information, and it seems that it really helped me get a very clear picture of the problem. I asked about her self-care related to her frequent urinary tract infections to get a good idea of what education and care she would need to prevent them. I should have addressed Mrs. Smith’s nutrition plan. This would help her manage her obesity, which is probably contributing to her low back pain. I should have asked Mrs. Smith about the possibility of quitting smoking and about whether she had ever tried to quit (Stead et al., 2008). When I reviewed my transcript,it became apparent that I kept it purely medical and rarely asked any social or cultural questions. I used Jarvis to ask the subjective questions but didn’t think much about finding much else out. This has been really good for me to remember to think of my patients as people with families and lives as well as medical problems.Citation: Stead, L. F., Bergson, G., & Lancaster, T. (2008). Physician advice for smoking cessation. Co- chrane Database Syst Rev, 2 (2). This reflection describes the experience. It also describes clinical reasoning and supporting citation. It demonstrates analysis of missed items. It recognizes assumptions and failings, and it addresses how these may be addressed in the future. |
Mrs. Smith was a very easy patient to interview. I used OLDCARTS to interview her, and it worked well. I think I really did well. I missed a few things about her diet and personal hygiene, but I won’t forget about these things in the future. –
While the student identified areas that should improve, he or she does not make a specific and measurable improvement plan or challenge any of his or her assumptions or practices. The reflection is incomplete with limited introspection.
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I loved this experience! –
This is an incomplete reflection. A deep reflection should explain what about the experience was found to be meaningful and how it can help one become a better nurse. Deep reflections involve practitioners examining and questioning their practices and assumptions.
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HEENT
The HEENT exam is an interview and physical exam that is concerned with the head, eyes, ears, nose and throat. It is performed when a patient presents with a problem with the HEENT system.
Patient narrative: For the last week your patient, Tina Jones, has experienced sore, itchy throat, itchy eyes, and runny nose.
She states that these symptoms started spontaneously and have been constant in nature. She states that her nose “runs all day”.
Plan your time:
- Review the assignment settings your instructor selected on the assignment overview page.
- Every assignment setting allows you to stop and resume an assignment until you leave the patient’s room. Your progress is automatically saved every 30 seconds.
Assignment | First Turn In | Allow Reopening | Flexible Turn In |
Time Estimate | ~75 minutes | ~115 minutes | ~160 minutes |
Getting Started: View this tutorial for guidance on getting started with the HEENT Assignment.
Tips for Success:
You should prepare prior to entering Ms. Jones’ room. We suggest taking out your textbook to remind yourself of what doing an HEENT exam entails. There are essential sections of patient information that your interview will need to uncover. There are multiple essential questions for each of these topics:
- Chief Complaint
- History of Present Illness
- Medical History pertaining to the HEENT system
- Targeted Review of Symptoms related to the HEENT system
- Targeted Family History related to the HEENT system
Know all of your qualifying questions for any symptom that may be reported:
- Onset
- Location
- Duration
- Characteristics
- Aggravating/alleviating factors
- Related symptoms
- Treatments tried
Remember when you are doing these exams that this simulation is designed to help you improve your assessment skills. Preparing ahead of time will help to set you up for success.
Respiratory
The respiratory exam is an interview and physical assessment that is performed when a patient presents with a respiratory problem or a history that is suggestive of a pathology of the lungs.
Patient narrative: Tina had an asthma episode 2 days ago. At that time she used her albuterol inhaler and her symptoms decreased although they did not completely resolve. Since that incident she notes that she has had 10 episodes of wheezing and has shortness of breath approximately every four hours. Tina presents with continued shortness of breath and wheezing.
Plan your time:
- Review the assignment settings your instructor selected on the assignment overview page.
- Every assignment setting allows you to stop and resume an assignment until you leave the patient’s room. Your progress is automatically saved every 30 seconds.
Assignment | First Turn In | Allow Reopening | Flexible Turn In |
Time Estimate | ~75 minutes | ~95 minutes | ~130 minutes |
Getting Started: View this tutorial for guidance on getting started with the Respiratory Assignment.
Tips for success: You should prepare prior to entering Ms. Jones’ room. We suggest taking out your textbook to remind yourself of what doing a respiratory assessment entails. There are essential sections of patient information that your interview will need to uncover. There are multiple essential questions for each of these topics:
| Chief Complaint |
| History of Present Illness |
| Medical history pertaining to the respiratory system |
| Social history pertaining to the respiratory system |
| Targeted review of systems related to the respiratory system |
| Family history related to the respiratory system |
Know all of your qualifying questions for any symptom that may be reported:
| Onset |
| Location |
| Duration |
| Characteristics |
| Aggravating/alleviating factors |
| Related symptoms |
| Treatments tried |
Cardiovascular
The cardiovascular exam is an interview and physical assessment that is performed when a patient presents with symptoms suggestive of a pathology of the heart such as chest pain or high blood pressure.
Patient narrative: Over the last month, Tina has experienced 3-4 episodes of perceived rapid heart rate. She describes these episodes as “thumping in her chest” with a heart rate that is “way faster than usual”.
Plan your time:
- Review the assignment settings your instructor selected on the assignment overview page.
- Every assignment setting allows you to stop and resume an assignment until you leave the patient’s room. Your progress is automatically saved every 30 seconds.
Assignment | First Turn In | Allow Reopening | Flexible Turn In |
Time Estimate | ~75 minutes | ~95 minutes | ~130 minutes |
Getting Started: View this tutorial for guidance on getting started with the Cardiovascular Assignment.
Tips for success: You should prepare prior to entering Ms. Jones’ room. We suggest taking out your textbook to remind yourself of what doing a cardiovascular assessment entails. There are essential sections of patient information that your interview will need to uncover. There are multiple essential questions for each of these topics:
| Chief Complaint |
| History of Present Illness |
| Medical history pertaining to the cardiovascular system |
| Social history pertaining to the cardiovascular system |
| Targeted review of systems related to the cardiovascular system |
| Family history related to the cardiovascular system |
Know all of your qualifying questions for any symptom that may be reported:
| Onset |
| Location |
| Duration |
| Characteristics |
| Aggravating/alleviating factors |
| Related symptoms |
| Treatments tried |
Abdominal
The abdominal exam is an interview and physical assessment that aims to pick up on any gastrointestinal pathology that may be causing symptoms such as abdominal pain, distention, or altered bowel habits.
Patient narrative: For “at least a month,” Tina has been experiencing burping after she eats and pain in her upper stomach after eating, which she describes as “kind of like heartburn, but sharper.” Plan your time:
- Review the assignment settings your instructor selected on the assignment overview page.
- Every assignment setting allows you to stop and resume an assignment until you leave the patient’s room. Your progress is automatically saved every 30 seconds.
Assignment | First Turn In | Allow Reopening | Flexible Turn In |
Time Estimate | ~75 minutes | ~95 minutes | ~130 minutes |
Getting Started: View this tutorial for guidance on getting started with the Abdominal Assignment.
Tips for success: You should prepare prior to entering Ms. Jones’ room. We suggest taking out your textbook to remind yourself of what doing an abdominal assessment entails. There are essential sections of patient information that your interview will need to uncover. There are multiple essential questions for each of these topics:
| Chief Complaint |
| History of Present Illness |
| Medical history pertaining to the gastrointestinal system |
| Social history pertaining to the gastrointestinal system |
| Targeted review of systems related to the gastrointestinal system |
| Family history related to the gastrointestinal system |
Know all of your qualifying questions for any symptom that may be reported:
| Onset |
| Location |
| Duration |
| Characteristics |
| Aggravating/alleviating factors |
| Related symptoms |
| Treatments tried |
Musculoskeletal
The musculoskeletal exam is an interview and physical assessment that assesses the overall functionality of the muscles and bones.
Patient narrative: Three days ago, Ms. Jones injured “tweaked” her back lifting a box. She has pain is in her lower back and bilateral buttocks. She presents today as the pain has continued and is interfering with her activities of daily living.
Plan your time:
- Review the assignment settings your instructor selected on the assignment overview page.
- Every assignment setting allows you to stop and resume an assignment until you leave the patient’s room. Your progress is automatically saved every 30 seconds.
Assignment | First Turn In | Allow Reopening | Flexible Turn In |
Time Estimate | ~75 minutes | ~95 minutes | ~130 minutes |
Getting Started: View this tutorial for guidance on getting started with the Musculoskeletal Assignment.
Tips for success: You should prepare prior to entering Ms. Jones’ room. We suggest taking out your textbook to remind yourself of what doing a musculoskeletal assessment entails. There are essential sections of patient information that your interview will need to uncover. There are multiple essential questions for each of these topics:
| Chief Complaint |
| History of Present Illness |
| Medical history pertaining to the musculoskeletal system |
| Social history pertaining to the musculoskeletal system |
| Targeted review of systems related to the musculoskeletal system |
| Family history related to the musculoskeletal system |
Know all of your qualifying questions for any symptom that may be reported:
| Onset |
| Location |
| Duration |
| Characteristics |
| Aggravating/alleviating factors |
| Related symptoms |
| Treatments tried |
Neurological
The neurologic exam is an interview and physical assessment that assesses the nervous system, which includes the brain and spinal cord.
Patient narrative: Two days after a minor, low-speed car accident, Tina noticed daily headaches along with neck pain and stiffness.
Plan your time:
- Review the assignment settings your instructor selected on the assignment overview page.
- Every assignment setting allows you to stop and resume an assignment until you leave the patient’s room. Your progress is automatically saved every 30 seconds.
Assignment | First Turn In | Allow Reopening | Flexible Turn In |
Time Estimate | ~90 minutes | ~115 minutes | ~160 minutes |
Getting Started: View this tutorial for guidance on getting started with the Neurological Assignment.
Tips for success: You should prepare prior to entering Ms. Jones’ room. We suggest taking out your textbook to remind yourself of what doing a neurologic assessment entails. There are essential sections of patient information that your interview will need to uncover. There are multiple essential questions for each of these topics:
| Chief Complaint |
| History of Present Illness |
| Medical history pertaining to the neurologic system |
| Social history pertaining to the neurologic system |
| Targeted review of systems related to the neurologic system |
| Family history related to the neurologic system |
Know all of your qualifying questions for any symptom that may be reported:
| Onset |
| Location |
| Duration |
| Characteristics |
| Aggravating/alleviating factors |
| Related symptoms |
| Treatments tried |
Mental Health
The mental health exam is an interview and that will give you an idea of how your patient is doing emotionally and cognitively. In this exam you will have the opportunity to will take note of how your patients look, their mood, behavior, thinking, reasoning, and their capacity to remember things.
Patient narrative: Tina has been having disturbed sleep 4- 5 nights a week. She complains of difficulty falling asleep at least 4 or 5 nights per week, but states that she is able to stay asleep without difficulty.
Plan your time:
- Review the assignment settings your instructor selected on the assignment overview page.
- Every assignment setting allows you to stop and resume an assignment until you leave the patient’s room. Your progress is automatically saved every 30 seconds.
Assignment | First Turn In | Allow Reopening | Flexible Turn In |
Time Estimate | ~90 minutes | ~115 minutes | ~160 minutes |
Getting Started: View this tutorial for guidance on getting started with the Mental Health Assignment.
Tips for success: You should prepare prior to entering Ms. Jones’ room. We suggest taking out your textbook to remind yourself of what doing a mental health assessment entails. There are essential sections of patient information that your interview will need to uncover. There are multiple essential questions for each of these topics:
| Chief Complaint |
| History of Present Illness |
| Medical history pertaining to mental health |
| Psychological history |
| Social History – Education, Work, Housing, and Support Network |
| Social History – Substance Abuse |
| Social History – Relationship and Sexual History |
| Family history related to mental health |
Know all of your qualifying questions for any symptom that may be reported:
| Onset |
| Location |
| Duration |
| Characteristics |
| Aggravating/alleviating factors |
| Related symptoms |
| Treatments tried |
Focused Exam: Cough
Daniel “Danny” Rivera is an 8-year-old boy who comes to the clinic with a cough. You will determine if Danny is in distress, explore the underlying cause of his cough, and look for related symptoms in other body systems.
Plan your time:
- Review the assignment settings your instructor selected on the assignment overview page.
- Every assignment setting allows you to stop and resume an assignment until you leave the patient’s room. Your progress is automatically saved every 30 seconds.
Assignment | First Turn In | Allow Reopening | Flexible Turn In |
Time Estimate | ~75 minutes | ~95 minutes | ~130 minutes |
Getting Started: View this tutorial for guidance on getting started with the Focused Exam: Cough Assignment.
Tips for success:
You should prepare prior to meeting Danny Rivera in the clinic. We suggest taking out your textbook to remind yourself of what doing a focused, complaint oriented respiratory exam entails. There are essential sections of patient information that your interview will need to uncover. There are multiple essential questions for each of these topics:
| Chief Complaint |
| History of Present Illness |
| Medical History |
| Social History related to the respiratory system |
| Targeted review of systems related to the chief complaint |
| Family History related to the chief complaint |
Know all of your qualifying questions for any symptom that may be reported:
| Onset |
| Location |
| Duration |
| Characteristics |
| Aggravating/alleviating factors |
| Related symptoms |
| Treatments tried |
Focused Exam: Chest Pain
Mr. Brian Foster, 58, has been having some troubling pain in his chest now and then for the past month.
Plan your time:
- Review the assignment settings your instructor selected on the assignment overview page.
- Every assignment setting allows you to stop and resume an assignment until you leave the patient’s room. Your progress is automatically saved every 30 seconds.
Assignment | First Turn In | Allow Reopening | Flexible Turn In |
Time Estimate | ~75 minutes | ~95 minutes | ~130 minutes |
Getting Started: View this tutorial for guidance on getting started with the Focused Exam: Chest Pain Assignment.
Tips for success:
You should prepare prior to meeting Brian Foster in the clinic. We suggest taking out your textbook to remind yourself of what doing a focused, complaint oriented cardiovascular exam assessment entails. There are essential sections of patient information that your interview will need to uncover. There are multiple essential questions for each of these topics:
| Chief Complaint |
| History of Present Illness (HPI) |
| Medical History |
| Social History |
| Family history related to the cardiovascular system |
| Targeted review of systems related to the chief complaint |
Know all of your qualifying questions for any symptom that may be reported:
| Onset |
| Location |
| Duration |
| Characteristics |
| Aggravating/alleviating factors |
| Related symptoms |
| Treatments tried |
Focused Exam: Abdominal Pain
Mrs. Esther Park is a 78-year-old woman who comes to the clinic complaining of abdominal pain. She reports that the pain isn’t severe, but that her daughter was concerned and brought her in.
Plan your time:
- Review the assignment settings your instructor selected on the assignment overview page.
- Every assignment setting allows you to stop and resume an assignment until you leave the patient’s room. Your progress is automatically saved every 30 seconds.
Assignment | First Turn In | Allow Reopening | Flexible Turn In |
Time Estimate | ~75 minutes | ~95 minutes | ~130 minutes |
Getting Started: View this tutorial for guidance on getting started with the Focused Exam: Abdominal Pain Assignment.
Tips for success:
You should prepare prior to meeting Esther Park in your clinic. We suggest taking out your textbook to remind yourself of what doing a focused, complaint oriented abdominal exam assessment entails. There are essential sections of patient information that your interview will need to uncover. There are multiple essential questions for each of these topics:
| Chief Complaint |
| History of Present Illness (HPI) |
| Medical History |
| Social History |
| Targeted review of systems related to the Chief Complaint |
Know all of your qualifying questions for any symptom that may be reported:
| Onset |
| Location |
| Duration |
| Characteristics |
| Aggravating/alleviating factors |
| Related symptoms |
| Treatments tried |
Comprehensive Assessment
In this assignment, your patient, Tina Jones presents in your outpatient clinic for a complete health assessment for a preemployment physical. This visit takes place approximated 18 months after Ms. Jones first established primary care in your clinic.
Plan your time:
- Review the assignment settings your instructor selected on the assignment overview page.
- Every assignment setting allows you to stop and resume an assignment until you leave the patient’s room. Your progress is automatically saved every 30 seconds.
Assignment | First Turn In | Allow Reopening | Flexible Turn In |
Time Estimate | ~180 minutes | ~225 minutes | ~315 minutes |
Getting Started: View this tutorial for guidance on getting started with the Comprehensive Assessment Assignment.
Tips for success:
You should prepare prior to seeing Ms. Jones. We suggest taking out your textbook to remind yourself of what taking doing a complete health assessment entails. There are essential sections of patient information that your interview will need to uncover. There are multiple essential questions for each of these topics:
| Reason for Visit |
| Medications |
| Allergies |
| Medications |
| Medical History |
| Psychosocial History |
| Health Maintenance |
| Mental Health History |
| General Review of Systems |
Know all of your qualifying questions for any symptom that may be reported:
| Onset |
| Location |
| Duration |
| Characteristics |
| Aggravating/alleviating factors |
| Related symptoms |
| Treatments tried |