NURS 6512 Week 9 Assignment 1: Shadow Health Comprehensive SOAP Note Essay

NURS 6512 Week 9 Assignment 1: Shadow Health Comprehensive SOAP Note Essay

Patient Initials: J. L                 Age: 28                       Gender: Female

SUBJECTIVE DATA:

Chief Complaint (CC): “I came in because I’m required to have a recent physical exam for the health insurance at my new job.”

History of Present Illness (HPI): No present illness. The patient is currently doing well.

J.L is a 28-year-old African American female who presents for a pre-employment physical after securing employment at Smith, Stevens, Stewart, Silver & Company, a requirement prior to commencement. She denies any acute concerns today. Following her annual gynecological exam during Her last healthcare visit 4 months ago at Shadow Health General Clinic, she was diagnosed with polycystic ovarian syndrome and was initiated on oral contraceptives which she has well tolerated. She also has type 2 diabetes, well-controlled with diet, exercise, and metformin, which she just started 5 months ago. Currently no medication adverse effects. She states that she feels healthy, takes care of herself better than in the past, and looks forward to beginning the new job.

Medications:

• Drospirenone and Ethinyl estradiol PO QD (last use: this morning)
• Metformin, 850 mg PO BID (last use: this morning)
• Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning)
• Acetaminophen 500-1000 mg PO prn (headaches)
• Ibuprofen 600 mg PO TID PRN (menstrual cramps: last taken 6 weeks ago)
• Albuterol 90 mcg/spray MDI 2 puffs Q4H PRN (last use: three months ago).

Allergies: Allergic to cats and dust, causes sneezing, swelling of eyes, itchiness, runny nose, and breathing difficulties exacerbating her asthma symptoms. She reports a rash after taking penicillin. She denies food and latex allergies.

Past Medical History (PMH): She has type 2 diabetes, diagnosed at 24 years, that is well controlled by metformin, diet, and exercise. A history of hypertension that normalized following initiation of exercise and dietary measures. Asthmatic since 2 and a half years old, on albuterol and fluticasone. Her last hospitalization was while in high school due to asthma. The latest asthma exacerbation was 3 months ago and resolved with the inhaler use. Daily blood sugar monitoring with average readings around 90 mg/dl.

Past Surgical History (PSH): No previous surgeries. No history of blood transfusion.

Sexual/Reproductive History: Menarche at 11 years, sexual debut at 18 years, heterosexual, and her LMP was a fortnight ago. She was diagnosed with PCOS four months ago. A regular cycle of 28 days for the last four months after being initiated on combined oral contraceptives. Her menses last five days with moderate bleeding. She is in a new male relationship and has yet to initiate sexual contact. Negative for HIV/AIDS and STIs (last test four months ago).

Personal/Social History: Single, no children, stays with her mother and sister in a single-family home. She enjoys reading, attending Bible study, volunteering in church, and dancing. Also enjoys hanging out with friends 2-3 times per month during which she uses alcohol but not more than 3 drinks per episode. History of cannabis use from 15 to 21 years. However, no use of illicit drugs or tobacco. Ordinary breakfast is a frozen fruit smoothie with unsweetened yogurt, lunch is low-fat pita or vegetables on brown rice or sandwich on wheat bread while dinner is vegetables with a protein. She takes carrot sticks or an apple as a snack. Denies coffee intake but takes 1-2 diet sodas per day. Participates in mild to moderate exercises four to five times weekly. No pets or recent travel.

Health Maintenance: She sees her primary care physician as scheduled. Does regular exercises and she is compliant with her medication. Her diet is as recommended by her dietician. Her last pap smear was 4 months ago, her last PPD was 2 years ago (negative), her last eye exam 3 months ago and her last dental exam was 5 months ago. Uses sunscreens.

Immunization History: Received all the childhood vaccines according to the immunization schedule. Has also received the meningococcal vaccine for college as well as a tetanus booster last year. However, influenza and human papillomavirus vaccines have not been received.

Significant Family History: Her mother is 50 years old, and has hypertension and high cholesterol levels. Father passed on last year aged 58 years following a car accident although he had type 2 diabetes, hypertension, and high cholesterol levels. Her brother is 25 years, overweight while her sister is 14 years and asthmatic. Maternal grandfather and grandmother died at 78 and 73 years respectively due to stroke. Both had hypertension and elevated cholesterol levels. Her paternal grandfather had type 2 diabetes although he passed on at 65 years due to colon cancer while her paternal grandmother is alive, 82 years but hypertensive. Her paternal uncle has alcohol use disorder. Otherwise, there is no family history of sickle cell disease, kidney disease, mental illness, other cancers, or sudden death.

Review of Systems:

General: No weight loss, fever, chills, and night sweats

            HEENT: Atraumatic.  No headaches, vision changes, eye pain, dryness, itchy or red eyes. Uses corrective lenses and visits optometrist (last visit 3 months ago). Reports no problem with hearing, ear pain, or discharge. Reports no alteration in sense of smell, sinus pain, sneezing, epistaxis, or rhinorrhea. No alterations in taste sensation, dry mouth, pain, sores, gum, jaw, or tongue abnormalities. No dental issues (last dental visit 5 months ago), hoarseness, sore throat, dysphagia, or swollen nodes.

            Respiratory: No chest pain, dyspnea, cough, sputum, or wheezing.

            Cardiovascular/Peripheral Vascular: No palpitations, edema, orthopnea, paroxysmal nocturnal dyspnea, tachycardia, or easy bruising.

            Gastrointestinal: Denies nausea, vomiting, diarrhea, constipation, excessive flatulence, food intolerance, and abdominal pain,

            Genitourinary: Denies vaginal discharge, itchiness, dysuria, flank pain, hematuria, nocturia, and polyuria.

            Musculoskeletal: No joint pain, muscle pain, muscle swelling, or joint stiffness.

            Neurological: Denies dizziness, lightheadedness, seizures, sense of disequilibrium, tingling sensation, or loss of coordination.

            Psychiatric: Denies depression, anxiety, or suicidal ideation. Reports decreased stress and improved sleep.

            Skin/hair/nails: Reports improvement of acne, facial and body hair. Reports a few moles and cessation of darkening of the skin around her neck. Denies nail changes.

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OBJECTIVE DATA:

Physical Exam:

Vital signs: Blood pressure- 128/82 mmHg, heart rate- 78 beats/min, respiratory rate- 15 breaths/min, temperature-99.0 F, saturation- 99% on room ar.

Weight: 170cm

Height: 84 kg

BMI: 29.0

Blood glucose: 100 mg/dl

General: A young African American lady, well-groomed and kempt, not in any form of distress, well-hydrated, and well-nourished. No central or peripheral cyanosis, no pallor, no jaundice, no cervical, inguinal or axillary lymphadenopathy. No peripheral edema.

HEENT: Normocephalic and atraumatic head. Eyes bilaterally present with equal hair distribution on eyebrows and lashes. No lid lesions, ptosis, or edema. Pink conjunctiva and white non-icteric sclera. Pupils are equal, round, reacting to light and accommodation bilaterally. Extraocular movements equal bilaterally, with no nystagmus. Mild retinopathic changes on right. Left fundus with sharp disc margins, no retinal hemorrhages. Snellen: 20/20 right eye, 20/20 left eye with corrective lenses. Tympanic membrane intact and pearly gray bilaterally, positive light reflex. Whispered words heard bilaterally. Frontal and maxillary sinuses nontender to palpation. The nasal mucosa is moist and pink with a midline septum. Moist oral mucosa without ulcerations or lesions, uvula rises midline on phonation. Intact gag reflex. Dentition without evidence of caries or infection. Tonsils 2+ bilaterally. Thyroid smooth without nodules, no goiter. No lymphadenopathy.

Neck: Soft, no tenderness, masses, or jugular venous distension. Non-rigid with a full range of motion. No lymphadenopathy.

Chest/Lungs:

Inspection: Chest moves with respiration symmetrically, no scars, visible lesions, or masses on the anterior and posterior aspects.

Palpation: Non-tender, equal tactile fremitus bilaterally.

Percussion: Resonant throughout.

Auscultation: Equal air entry bilateral, vesicular breath sounds, no wheezes, cough, and crackles bilaterally. Equal vocal fremitus.

Spirometry: FVC3.91L, FEV1/FVC ratio 80.56%

Heart/Peripheral Vascular: Normoactive precordium, PMI in the fifth intercostal space left midclavicular line. Regular heart rate, S1 and S2 clear and distinct, no murmurs, rubs, gallops, heaves, lifts, or thrills. Equal bilateral carotid pulses 3+, no bruits or thrills. Equal bilateral peripheral pulses 2+, no bruits or thrills. Capillary refill is 2 seconds in all the digits. No peripheral edema.

Abdomen:

Inspection: A protuberant symmetric abdomen, moving with respiration, umbilicus everted, no visible masses, scars, or lesions. Coarse of hair pubis to the umbilicus.

Auscultation: Normoactive bowel sounds in all the quadrants, no bruits over renal, aortic, or iliac arteries.

Palpation: Warm and soft to touch, no masses, no tenderness or guarding, the liver edge is 1 cm below the right costal margin. The spleen and bilateral kidneys are impalpable.

Percussion: Tympanic throughout.

Genital/Rectal: Clean external genitalia, normal shape and color of labia majora and minor, and no discharges. Vaginal mucosa looks, moist, wet, and pink with no signs of inflammation. No cervical motion tenderness. No hemorrhoids or anal fissures, intact anal tone.

Musculoskeletal: Full range of motions across all joints, power of 5/5 in all muscle groups of both upper and lower limbs. DTR +2, no deformity, CVA tenderness, masses, swelling, or pain with movement.

Neurological: Alert, GCS 15/15, oriented to time, place, and person, intact short term, intermediate and long-term memory, coherent and appropriate speech, good intelligence, all cranial nerves intact. Good bulk, normotonia, power 5/5 in all muscle groups of both upper and lower limbs, deep tendon reflexes 2+ and equal bilaterally in both upper and lower limbs. Crude touch, vibration, temperature, and proprioception sensations are intact in all dermatomes. Normal stereognosis. Light touch is normal in all dermatomes except bilateral plantar surfaces. Cerebellar function: normal finger nose, rapid alternating movements, and heel to shin tests. Steady gait. Normal graphesthesia. Good bowel and bladder function, no spinal tenderness.

Skin: Normal scalp skin, scattered pustules on the face. Facial hair on the upper lip, Acanthosis nigricans on the posterior neck. An old scar on the left shin. Free nail ridges.

 

Diagnostic results:

 

ASSESSMENT:

 

PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.

Week 9: Assessment of Cognition and the Neurologic System
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.
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.
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

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.

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.

Kim, H., Lee, S., Ku, B. D., Ham, S. G., & Park, W. (2019). Associated factors for cognitive impairment in the rural highly elderly. Brain and Behavior, 9(5), e01203. https://doi.org/10.1002/brb3.1203

Lee, K., Puga, F., Pickering, C. E., Masoud, S. S., & White, C. L. (2019). Transitioning into the caregiver role following a diagnosis of Alzheimer’s disease or related dementia: A scoping review. International Journal of Nursing Studies, 96, 119–131. https://doi.org/10.1016/j.ijnurstu.2019.02.007

O’Caoimh, R., & Molloy, D. W. (2019). Comparing the diagnostic accuracy of two cognitive screening instruments in different dementia subtypes and clinical depression. Diagnostics, 9(3), 93. https://doi.org/10.3390/diagnostics9030093

Shadow Health Support and Orientation Resources
Use the following resources to guide you through your Shadow Health orientation as well as other support resources:

Shadow Health. (2021). Welcome to your introduction to Shadow Health. https://link.shadowhealth.com/Student-Orientation-Video

Shadow Health. (n.d.). Shadow Health help desk. Retrieved from https://support.shadowhealth.com/hc/en-us

Shadow Health. (2021). Walden University quick start guide: NURS 6512 NP students. https://link.shadowhealth.com/Walden-NURS-6512-Student-Guide

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
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2020). DeGowin’s diagnostic examination (11th ed.). New York, NY: McGraw Hill Medical.
• Chapter 14, “The Neurologic Examination”

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”

In this chapter, the authors provide a list of common psychiatric syndromes. The authors also explain the mental, psychiatric, and social evaluation process.

Required Media (click to expand/reduce)

Neurologic System – Week 9 (16m)

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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/
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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.
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.
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.
• Click on the Submit button to complete your submission.
Grading Criteria

To access your rubric:
Week 9 Assignment 1 Rubric

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: 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 a 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
Complete the following in Shadow Health:
• Neurological (Practice)
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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.

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.
• Also, your Week 9 Assignment 3 should be in the Complete SOAP Note format. Refer to Chapter 2 of the Sullivan text and the Week 4 Complete Physical Exam template and use the template below for your submission.

Week 9 Shadow Health Comprehensive SOAP Note Documentation Template

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
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
• Review the Week 9 DCE Health History Assessment Rubric, provided in the Assignment submission area, for details on completing the Assignment.
• Complete your documentation using the documentation template in your resources and submit it into your Assignment submission link below.
• From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database
• Complete the Code of Conduct Acknowledgement.
• 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

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 Student Acknowledgement:

Click here and follow the instructions to confirm you have complied with Walden University’s Code of Conduct including the expectations for academic integrity while completing the Shadow Health Assessment
What’s Coming Up in Week 10?

Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images
Next week, you will examine how to assess problems with the breasts, genitalia, rectum, and prostate while making the patient feel safe, listened to, and cared about using a non-invasive approach. Once again, you will use a SOAP note format to complete your Lab Assignment for this week.
Week 10 Required Media

Photo Credit: [fergregory]/[iStock / Getty Images Plus]/Getty Images
Next week, you will need to view several videos and animations in the Seidel’s Guide to Physical Examination as well as other media, as required, prior to completing your Discussion. There are several videos of various lengths. Please plan ahead to ensure you have time to view these media programs to complete your Lab Assignment on time.
Next Week

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To go to the next week:
Week 10

NURS_6512_Week_9_Assignment1_Rubric

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		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.		Points Range: 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.	Points Range: 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.	Points Range: 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.	Points Range: 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.		Points Range: 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.	Points Range: 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.	Points Range: 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.	Points Range: 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.		Points Range: 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.	Points Range: 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.	Points Range: 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.	Points Range: 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		Points Range: 5 (5%) – 5 (5%) Uses correct grammar, spelling, and punctuation with no errors.	Points Range: 4 (4%) – 4 (4%) Contains a few (1 or 2) grammar, spelling, and punctuation errors.	Points Range: 3 (3%) – 3 (3%) Contains several (3 or 4) grammar, spelling, and punctuation errors.	Points Range: 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.		Points Range: 5 (5%) – 5 (5%) Uses correct APA format with no errors.	Points Range: 4 (4%) – 4 (4%) Contains a few (1 or 2) APA format errors.	Points Range: 3 (3%) – 3 (3%) Contains several (3 or 4) APA format errors.	Points Range: 0 (0%) – 2 (2%) Contains many (≥ 5) APA format errors.
Total Points: 100

Name: NURS_6512_Week_9_Assignment1_Rubric