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Week 5 - Focused Exam: Cough, Danny Rivera - REQUIRED Results | Turned In Advanced Health Assessment and Diagnostic Reasoning - NP - February 2022, nurs6512-laureate_higher_education_group-202250

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Your Results

Reopen Lab Pass

• Overview
• Transcript
• Subjective Data Collection
• Objective Data Collection
• Education & Empathy
• Documentation
• Program Competency Progress

Experience Overview

Patient: Danny Rivera

Danny Rivera.

Digital Clinical Experience Score

97.5%

This score measures your performance on the Student Performance Index in relation to other students in comparable academic programs. Your instructor has chosen to scale your Student Performance Index score so that the average score on the index is a 80.0%. This score may not be your final grade if your instructor chooses to include additional components, such as documentation or time spent.

Student Performance Index

36.87 out of 39

Proficiency Level:

Proficient

• Beginning
• Developing
• Proficient

Students rated as “beginning” are starting to develop their advanced practice competencies and clinical reasoning skills. In comparable programs, 50% of students perform at the level of a beginning practitioner. Review your results in the tabs on the left side of the page to identify areas for improvement. Students rated as “developing” demonstrate increasing clinical reasoning abilities as they apply their knowledge of advanced practice competencies. In comparable programs, 25% of students perform at the level of a developing practitioner. Review your results in the tabs on the left side of the page to identify areas for improvement. Students rated as “proficient” demonstrate an entry-level expertise in advanced practice competencies and clinical reasoning skills. In comparable programs, the top 25% of students perform at the level of a proficient practitioner.

Subjective Data Collection

21 out of 21

Objective Data Collection

11.87 out of 13

Education and Empathy

4 out of 5

Time

83 minutes total spent in assignment

Interaction with patient

83 minutes

Transcript

Started: Mar 29, 2022 | Total Time: 83 min All Lines (122) Interview Questions (79) Statements (7) Exam Actions (36)

Your Avatar.	hello my name is Mary Sarfo and will be taking care of you and conducting your assessment .	Greet 03/29/22 12:04 AM MDT
Danny Rivera.	Hi.
Your Avatar.	what is your name	Question 03/29/22 12:04 AM MDT
Danny Rivera.	My name is Daniel Rivera, but I just go by Danny.
Your Avatar.	Hi Danny, how old are you? (Clarified to Hi, how are you?.)	Question 03/29/22 12:04 AM MDT
Danny Rivera.	My Abuela brought me here because I've been feeling sick. I have been coughing a lot. . . and I feel kinda tired. (Clarified to to say hello and ask how I am.)
Your Avatar.	I am sorry that you not feeling well	Empathize 03/29/22 12:05 AM MDT
Danny Rivera.	Thank you.
Your Avatar.	how old are you	Question 03/29/22 12:05 AM MDT
Danny Rivera.	I'm eight.
Your Avatar.	when is you birth date	Question 03/29/22 12:05 AM MDT
Danny Rivera.	I was born March 4th in, um . . . [Danny reports correct birth year.]
Your Avatar.	tell me what brings you in today	Question 03/29/22 12:06 AM MDT
Danny Rivera.	My Abuela brought me here because I've been feeling sick. I have been coughing a lot. . . and I feel kinda tired.
Your Avatar.	Do you have cough?	Question 03/29/22 12:06 AM MDT
Danny Rivera.	I guess I'm kind of sick. . . I've been coughing a lot.
Your Avatar.	when did the cough starts	Question 03/29/22 12:07 AM MDT
Danny Rivera.	I think the cough started four. . . No, it started five days ago.
Your Avatar.	how long have you had cough	Question 03/29/22 12:07 AM MDT
Danny Rivera.	I think the cough started four. . . No, it started five days ago.
Your Avatar.	tell me about how your cough is	Question 03/29/22 12:08 AM MDT
Danny Rivera.	I just keep feeling like I have to cough every couple minutes or so. I think it gets worse at night.
Your Avatar.	is your cough wet	Question 03/29/22 12:08 AM MDT
Danny Rivera.	Yeah . . . my cough seems kind of gurgly and watery.
Your Avatar.	how frequent do you cough	Question 03/29/22 12:08 AM MDT
Danny Rivera.	I just keep feeling like I have to cough every couple minutes or so. I think it gets worse at night.
Your Avatar.	how long do your cough last	Question 03/29/22 12:09 AM MDT
Danny Rivera.	I think the cough started four. . . No, it started five days ago.
Your Avatar.	what makes your cough worse	Question 03/29/22 12:09 AM MDT
Danny Rivera.	My cough mostly stays the same no matter what I do. It seems to get worse at night though.
Your Avatar.	is the cough worse at night?	Question 03/29/22 12:10 AM MDT
Danny Rivera.	Yeah, my cough's worse at night.
Your Avatar.	does your cough wakes you at night	Question 03/29/22 12:10 AM MDT
Danny Rivera.	I can't fall asleep much because I keep coughing.
Your Avatar.	do you smoke	Question 03/29/22 12:11 AM MDT
Danny Rivera.	No way! I know smoking is really bad--even for grown-ups. Papi smokes cigars sometimes. I don't like how they smell.
Your Avatar.	are you ever around cigarette smoke	Question 03/29/22 12:12 AM MDT
Danny Rivera.	Well . . . sometimes Papi smokes cigars in the house and my mom has to tell him to go outside. I breathe it a little bit then, but it's not all the time or anything. I don't like how it smells.
Your Avatar.	have you done anything to treat your cough?	Question 03/29/22 12:12 AM MDT
Danny Rivera.	I had some cough medicine this morning. [AUDIO COMING SOON]
Your Avatar.	what name was the cough medicine	Question 03/29/22 12:13 AM MDT
Danny Rivera.	I don't know what the name of the cough medicine is. It was purple. [AUDIO COMING SOON]
Your Avatar.	what color was the cough medicine	Question 03/29/22 12:14 AM MDT
Danny Rivera.	Um, it was purple-ish. It tasted gross.
Your Avatar.	how much cough medicine did you take	Question 03/29/22 12:14 AM MDT
Danny Rivera.	I just had one spoonful of it.
Your Avatar.	who gave you the cough medication	Question 03/29/22 12:15 AM MDT
Danny Rivera.	My mom.
Your Avatar.	how many times have you taken the cough syrup	Question 03/29/22 12:15 AM MDT
Danny Rivera.	I only took the cough medicine once. My mom gave me a spoonful. [AUDIO COMING SOON]
Your Avatar.	did it help with the cough (No matching questions found.)	Question 03/29/22 12:16 AM MDT
Your Avatar.	did it help with the cough (No matching questions found.)	Question 03/29/22 12:17 AM MDT
Your Avatar.	did it help with the cough (No matching questions found.)	Question 03/29/22 12:17 AM MDT
Your Avatar.	have you try any home remedies for your cough	Question 03/29/22 12:18 AM MDT
Danny Rivera.	I had some cough medicine this morning. [AUDIO COMING SOON]
Your Avatar.	do you take any medications from a doctor	Question 03/29/22 12:18 AM MDT
Danny Rivera.	No. [AUDIO COMING SOON]
Your Avatar.	do you take any vitamins	Question 03/29/22 12:18 AM MDT
Danny Rivera.	Oh yeah, I take vitamins every day! The gummy dinosaur kind. I don't think I'm supposed to, but sometimes I sneak extra ones to be super healthy!
Your Avatar.	taking too much vitamins can cause other health issues	Educate 03/29/22 12:19 AM MDT
Danny Rivera.	Oh, OK.
Your Avatar.	what other OTC do you take	Question 03/29/22 12:20 AM MDT
Danny Rivera.	Just when I'm sick and my mom or the doctor says I should take some medicine. My mom gave me some cough medicine this morning.
Your Avatar.	are you active most of the time	Question 03/29/22 12:20 AM MDT
Danny Rivera.	I have gym class every day. I do all my exercises there. And there's a park right next to my house where I play after school, or sometimes on the weekends, if it's nice outside. [AUDIO COMING SOON]
Your Avatar.	have you been less active since you been sick (No matching questions found.)	Question 03/29/22 12:21 AM MDT
Your Avatar.	have you been less active since you been sick (No matching questions found.)	Question 03/29/22 12:21 AM MDT
Your Avatar.	are you less active now	Question 03/29/22 12:22 AM MDT
Danny Rivera.	No, I don't feel nauseous.
Your Avatar.	has your activity changed since you been sick	Question 03/29/22 12:22 AM MDT
Danny Rivera.	I have gym class every day. I do all my exercises there. And there's a park right next to my house where I play after school, or sometimes on the weekends, if it's nice outside. [AUDIO COMING SOON]
Your Avatar.	are you able to keep up when you play with your classmates (No matching questions found.)	Question 03/29/22 12:23 AM MDT
Your Avatar.	are you able to focus	Question 03/29/22 12:23 AM MDT
Danny Rivera.	I can focus normally, but I couldn't sleep very well last night because of my coughing, so it was harder than normal. Plus, it's harder to pay attention when you keep having to cough. [AUDIO COMING SOON]
Your Avatar.	do you have runny nose	Question 03/29/22 12:24 AM MDT
Danny Rivera.	My nose is always a little bit runny... but ever since I started coughing it's been worse, I think.
Your Avatar.	have you been sneezing	Question 03/29/22 12:25 AM MDT
Danny Rivera.	I don't usually have to sneeze. My nose gets runny a lot of times though, like I have a cold.
Your Avatar.	what color is your snot	Question 03/29/22 12:25 AM MDT
Danny Rivera.	You mean like when I blow my nose? It's clear.
Your Avatar.	what is the consistency of your nasal drainage	Question 03/29/22 12:26 AM MDT
Danny Rivera.	It's kind of clear and, like, watery.
Your Avatar.	do you have any ear infection	Question 03/29/22 12:27 AM MDT
Danny Rivera.	I don't know if it is infected, but my right ear kind of hurts.
Your Avatar.	sorry to hear that	Empathize 03/29/22 12:27 AM MDT
Danny Rivera.	Thank you.
Your Avatar.	do you have any drainage from your ears	Question 03/29/22 12:27 AM MDT
Danny Rivera.	No, nothing comes out of my ears, but my right ear kind of hurts.
Your Avatar.	do you have any hearing problems	Question 03/29/22 12:28 AM MDT
Danny Rivera.	A lady came to my school to give all the kids a hearing test. It was kind of cool! I was hoping I would have super hearing, but I think I was just normal . . .
Your Avatar.	do you have any sore throat	Question 03/29/22 12:29 AM MDT
Danny Rivera.	It feels a little bit sore, yeah.
Your Avatar.	does it hurts when you swallow	Question 03/29/22 12:29 AM MDT
Danny Rivera.	No, I can swallow OK. It hurts a little right now because my throat is kinda sore.
Your Avatar.	do you get runny nose often	Question 03/29/22 12:31 AM MDT
Danny Rivera.	My nose is always a little bit runny... but ever since I started coughing it's been worse, I think.
Your Avatar.	do you have coughs often (Clarified to Are you coughing a lot?.)	Question 03/29/22 12:32 AM MDT
Danny Rivera.	I sometimes get coughs like this, but it's not all the time. I don't think it's a lot. I coughed a lot was when I had pneumonia one time. (Clarified to if I cough a lot.)
Your Avatar.	have you had pneumonia	Question 03/29/22 12:32 AM MDT
Danny Rivera.	I think I had that last year, when I was seven. My mom was really worried.
Your Avatar.	how did it get treated (No matching questions found.)	Question 03/29/22 12:33 AM MDT
Your Avatar.	do you have asthma	Question 03/29/22 12:33 AM MDT
Danny Rivera.	Is that when you have to use a, uh, an inhaler? My friend Tony does that sometimes, but I don't have to.
Your Avatar.	do you have asthma	Question 03/29/22 12:33 AM MDT
Danny Rivera.	Is that when you have to use a, uh, an inhaler? My friend Tony does that sometimes, but I don't have to.
Your Avatar.	are you up to date on your immunizations?	Question 03/29/22 12:34 AM MDT
Danny Rivera.	Like getting shots? It seems like I get shots whenever I go to the doctor. Mom says I need them for school, but I hate it.
Your Avatar.	shots are good to protect you from illness	Educate 03/29/22 12:35 AM MDT
Danny Rivera.	Oh, OK.
Your Avatar.	do you have seasonal allergies	Question 03/29/22 12:35 AM MDT
Danny Rivera.	I don't think I have any allergies like that.
Your Avatar.	do you have allergies to any medication	Question 03/29/22 12:38 AM MDT
Danny Rivera.	I don't think I'm allergic to medicine.
Your Avatar.	any allergies to food	Question 03/29/22 12:38 AM MDT
Danny Rivera.	I'm not allergic to any foods I don't think.
Your Avatar.	any family history of allergies	Question 03/29/22 12:38 AM MDT
Danny Rivera.	I don't think so, but I guess I'm not sure.
Your Avatar.	any family history of asthma	Question 03/29/22 12:39 AM MDT
Danny Rivera.	Only Papi had asthma, I think.
Your Avatar.	do you have fever	Question 03/29/22 12:39 AM MDT
Danny Rivera.	My mom said I didn't have a fever this morning before Abuela took me here.
Your Avatar.	do you have any chills	Question 03/29/22 12:40 AM MDT
Danny Rivera.	No, I haven't felt that.
Your Avatar.	do you have fatigue	Question 03/29/22 12:40 AM MDT
Danny Rivera.	Yeah, I feel kind of tired. I think it's because I couldn't sleep much at night. My cough kept me from falling asleep.
Your Avatar.	sorry to hear that	Empathize 03/29/22 12:40 AM MDT
Danny Rivera.	Thank you.
Your Avatar.	do you have night sweats	Question 03/29/22 12:41 AM MDT
Danny Rivera.	I don't sweat at night unless it gets really hot or something.
Your Avatar.	have you been sleeping okay	Question 03/29/22 12:41 AM MDT
Danny Rivera.	Most times I sleep OK, but I haven't been able to sleep much because of my cough.
Your Avatar.	do you notice any swelling	Question 03/29/22 12:41 AM MDT
Danny Rivera.	Nothing's swollen.
Your Avatar.	do you get frequent colds	Question 03/29/22 12:42 AM MDT
Danny Rivera.	I get colds a lot. My nose is always runny.
Your Avatar.	what medicine do you take for the runny nose (Clarified to Did you take medication for your runny nose?.)	Question 03/29/22 12:42 AM MDT
Danny Rivera.	I guess I don't do anything for my nose. I make sure to keep a tissue around so I can blow it, but it still keeps running. (Clarified to if I took medication to treat my runny nose.)
Your Avatar.	do you have headaches	Question 03/29/22 12:43 AM MDT
Danny Rivera.	I don't usually get headaches.
Your Avatar.	do you get nose bleeds	Question 03/29/22 12:43 AM MDT
Danny Rivera.	Just one time. Tony and I were kicking a ball at recess and I got hit in the nose.
Your Avatar.	sorry about that	Empathize 03/29/22 12:44 AM MDT
Danny Rivera.	Thank you.
Your Avatar.	do you have any vision problems	Question 03/29/22 12:44 AM MDT
Danny Rivera.	No, I see really good. Oh, I mean, I see well. I think glasses are kind of cool though. My friend Tony has them.
Your Avatar.	do you get dizzy	Question 03/29/22 12:45 AM MDT
Danny Rivera.	I only get dizzy if I'm spinning around a lot at recess.
Your Avatar.	do you have any sinus pain	Question 03/29/22 12:45 AM MDT
Danny Rivera.	It doesn't hurt there.
Your Avatar.	do you have chest pain	Question 03/29/22 12:45 AM MDT
Danny Rivera.	No, I don't have pain in my chest. I would hate that!
Your Avatar.	do you have any shortness of breath	Question 03/29/22 12:46 AM MDT
Danny Rivera.	My breathing seems good. My nose is kind of runny right now, but I can still breathe OK.
Your Avatar.	do you have any siblings	Question 03/29/22 12:46 AM MDT
Danny Rivera.	No, I'm the only kid in my house.
Your Avatar.	does your friend Tony gets runny nose too (Clarified to Is tony sick?.)	Question 03/29/22 12:47 AM MDT
Danny Rivera.	None of my friends are sick that I know of. (Clarified to if Tony is sick.)
Your Avatar.	Checked vitals	Exam Action 03/29/22 12:48 AM MDT
Your Avatar.	Inspected right orbital area and sclera	Exam Action 03/29/22 12:49 AM MDT
Your Avatar.	Inspected upper conjunctiva	Exam Action 03/29/22 12:49 AM MDT
Your Avatar.	Inspected upper conjunctiva	Exam Action 03/29/22 12:49 AM MDT
Your Avatar.	Inspected right orbital area and sclera	Exam Action 03/29/22 12:49 AM MDT
Your Avatar.	Inspected left orbital area and sclera	Exam Action 03/29/22 12:49 AM MDT
Your Avatar.	Inspected lower conjunctiva	Exam Action 03/29/22 12:50 AM MDT
Your Avatar.	Performed otoscopic examination of right naris	Exam Action 03/29/22 12:50 AM MDT
Your Avatar.	Performed otoscopic examination of left naris	Exam Action 03/29/22 12:51 AM MDT
Your Avatar.	Performed otoscopic examination of right ear	Exam Action 03/29/22 12:52 AM MDT
Your Avatar.	Performed otoscopic examination of left ear	Exam Action 03/29/22 12:52 AM MDT
Your Avatar.	Inspected mouth	Exam Action 03/29/22 12:53 AM MDT
Your Avatar.	Inspected front of neck	Exam Action 03/29/22 12:54 AM MDT
Your Avatar.	Inspected right side of neck	Exam Action 03/29/22 12:54 AM MDT
Your Avatar.	Inspected back of neck	Exam Action 03/29/22 12:54 AM MDT
Your Avatar.	Inspected right side of neck	Exam Action 03/29/22 12:55 AM MDT
Your Avatar.	Inspected front of neck	Exam Action 03/29/22 12:55 AM MDT
Your Avatar.	Inspected anterior chest wall	Exam Action 03/29/22 12:55 AM MDT
Your Avatar.	Inspected posterior chest wall	Exam Action 03/29/22 12:55 AM MDT
Your Avatar.	does resting help your cough	Question 03/29/22 1:57 AM MDT
Danny Rivera.	My cough has just stayed the same. I've taken some naps, but it doesn't seem to help.
Your Avatar.	does drinking water helps your cough	Question 03/29/22 1:58 AM MDT
Danny Rivera.	Drinking water doesn't do anything to my cough.
Your Avatar.	how long have had ear pain	Question 03/29/22 2:00 AM MDT
Danny Rivera.	My right ear just started hurting yesterday. I think it's because I'm sick.
Your Avatar.	Thanks for telling what you know about you and family history. That was a great job	Question 03/29/22 2:02 AM MDT
Danny Rivera.	My mom sometimes talks about her diabetes, cholesterol. . . Oh, and blood pressure. Papi talks about cholesterol too. He smokes too. I know that's bad.
Your Avatar.	That is too bad your papi smokes at home. secondhand smoking is bad for health. I can tell you bothers you a lot.	Empathize 03/29/22 2:04 AM MDT
Danny Rivera.	Thank you.
Your Avatar.	Percussed anterior right upper lobe	Exam Action 03/29/22 2:05 AM MDT
Your Avatar.	Percussed anterior left upper lobe	Exam Action 03/29/22 2:05 AM MDT
Your Avatar.	Percussed anterior right middle lobe	Exam Action 03/29/22 2:05 AM MDT
Your Avatar.	Percussed anterior left mid-chest (upper lobe)	Exam Action 03/29/22 2:05 AM MDT
Your Avatar.	Percussed anterior right lower lobe	Exam Action 03/29/22 2:05 AM MDT
Your Avatar.	Percussed anterior left lower lobe	Exam Action 03/29/22 2:05 AM MDT
Your Avatar.	Percussed posterior left upper lobe	Exam Action 03/29/22 2:05 AM MDT
Your Avatar.	Percussed posterior right upper lobe	Exam Action 03/29/22 2:05 AM MDT
Your Avatar.	Percussed posterior left mid-back (lower lobe)	Exam Action 03/29/22 2:05 AM MDT
Your Avatar.	Percussed posterior right mid-back (lower lobe)	Exam Action 03/29/22 2:05 AM MDT
Your Avatar.	Percussed posterior left lower lobe	Exam Action 03/29/22 2:05 AM MDT
Your Avatar.	Percussed posterior right lower lobe	Exam Action 03/29/22 2:05 AM MDT
Your Avatar.	Percussed posterior left lower lobe on side	Exam Action 03/29/22 2:05 AM MDT
Your Avatar.	Percussed posterior left lower lobe near spine	Exam Action 03/29/22 2:06 AM MDT
Your Avatar.	Percussed posterior right lower lobe near spine	Exam Action 03/29/22 2:06 AM MDT
Your Avatar.	Percussed posterior left right lobe on side	Exam Action 03/29/22 2:06 AM MDT
Your Avatar.	Percussed posterior left right lobe on side	Exam Action 03/29/22 2:06 AM MDT

Subjective Data Collection: 21 of 21 (100.0%)

Hover To Reveal...

Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

• Found: Indicates an item that you found.
• Available: Indicates an item that is available to be found.

Category

Scored Items

Experts selected these topics as essential components of a strong, thorough interview with this patient.

Patient Data

Not Scored

A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case.

Chief Complaint

• Finding:

  Established chief complaint

• Finding:

  Reports cough

  (Found)

  Pro Tip: A patient's chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.

  Example Question:

  Do you have a cough?

History of Present Illness

• Finding:

  Asked about onset of cough

• Finding:

  Reports cough started 5 days ago

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  How long have you had a cough?

• Finding:

  Asked about frequency and duration of cough

• Finding:

  Reports coughing every few minutes

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  How frequently have you been coughing?

• Finding:

  Asked about character of cough

• Finding:

  Reports cough is wet

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Is your cough a wet cough?

• Finding:

  Reports clear sputum

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Do you produce any phlegm or sputum with your cough?

• Finding:

  Asked about aggravating factors for cough

• Finding:

  Reports cough is worse at night

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Is your cough worse at night?

• Finding:

  Reports exposure to secondhand smoke

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Are you around anyone who smokes at home?

• Finding:

  Denies knowing what makes the cough worse

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  What makes your cough worse?

• Finding:

  Asked about relieving factors for cough

• Finding:

  Denies resting relieves cough

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Does resting help your cough?

• Finding:

  Denies drinking water relieves cough

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Does drinking water help your cough?

• Finding:

  Asked about nasal symptoms

• Finding:

  Reports current runny nose

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Do you have a runny nose?

• Finding:

  Denies sneezing

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Have you been sneezing?

• Finding:

  Reports frequent runny nose

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Do you get runny noses often?

• Finding:

  Followed up on nasal discharge

• Finding:

  Reports nasal discharge is clear

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  What color is your snot?

• Finding:

  Reports nasal discharge is thin

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Is your snot thin?

• Finding:

  Asked about ear symptoms

• Finding:

  Reports pain in right ear

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Do you have any ear pain?

• Finding:

  Followed up on ear pain

• Finding:

  Reports ear pain started yesterday

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  How long have you had ear pain?

• Finding:

  Reports ear pain is a 3 out of 10

  (Available)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Can you rate your ear pain on a scale?

• Finding:

  Denies ear discharge

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Do you have any ear discharge?

• Finding:

  Asked about throat symptoms

• Finding:

  Reports sore throat

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Is your throat sore?

• Finding:

  Reports "a little" pain with swallowing

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Does it hurt when you swallow?

• Finding:

  Asked about allergies

• Finding:

  Denies seasonal allergies

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Do you have seasonal allergies?

• Finding:

  Denies food allergies

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Do you have food allergies?

• Finding:

  Denies medication allergies

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Are you allergic to any medicine?

• Finding:

  Denies allergies to animals

  (Available)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Are you allergic to animals?

• Finding:

  Denies latex allergy

  (Available)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Are you allergic to latex?

• Finding:

  Asked about contact with illnesses

• Finding:

  Denies being around anyone ill at home

  (Available)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Is anyone sick at home?

Home Medications

• Finding:

  Asked about home medications

• Finding:

  Confirmed home medications

  (Found)

  Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation.

  Example Question:

  What medications do you take?

• Finding:

  Reports taking a daily vitamin

  (Found)

  Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation.

  Example Question:

  Do you take vitamins?

• Finding:

  Reports taking cough medicine

  (Found)

  Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation.

  Example Question:

  Are you taking medication for your cough?

• Finding:

  Followed up on cough medicine

• Finding:

  Reports cough medicine was purple

  (Found)

  Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation.

  Example Question:

  What color was the cough medicine?

• Finding:

  Reports taking one spoonful of cough medicine

  (Found)

  Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation.

  Example Question:

  How much cough medicine did you take?

• Finding:

  Reports mother gave him the medicine

  (Found)

  Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation.

  Example Question:

  Who gave you the cough medicine?

• Finding:

  Reports cough medicine provided temporary relief

  (Available)

  Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation.

  Example Question:

  Did the cough medicine make you feel better?

Past Medical History

• Finding:

  Asked about relevant medical history

• Finding:

  Denies asthma diagnosis

  (Found)

  Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  Do you have asthma?

• Finding:

  Reports immunizations as current

  (Found)

  Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  Do you have current immunizations?

• Finding:

  Reports past pneumonia and frequent coughs

  (Found)

  Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  Do you have a history of respiratory problems?

• Finding:

  Denies past hospitalizations

  (Available)

  Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  Have you ever been to the hospital?

Social Determinants of Health

• Finding:

  Asked about exposure to secondhand smoke

• Finding:

  Reports father smokes cigars

  (Found)

  Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

  Example Question:

  Who smokes at home?

• Finding:

  Reports father sometimes forgets to take cigars outside

  (Available)

  Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

  Example Question:

  Where does your father smoke?

Social History

• Finding:

  Asked about living conditions

• Finding:

  Reports living in a house with parents and grandparents

  (Available)

  Pro Tip: A patient's social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient's social history can also unveil the influence of their present illnesses in their social lives.

  Example Question:

  Where do you live?

• Finding:

  Reports feeling safe at home

  (Available)

  Pro Tip: A patient's social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient's social history can also unveil the influence of their present illnesses in their social lives.

  Example Question:

  Do you feel safe at home?

• Finding:

  Reports park with playground near home

  (Found)

  Pro Tip: A patient's social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient's social history can also unveil the influence of their present illnesses in their social lives.

  Example Question:

  Is there anywhere near your home where you can play outside?

Review of Systems

• Finding:

  Asked about constitutional health

• Finding:

  Denies fever

  (Found)

  Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you have a fever?

• Finding:

  Denies chills

  (Found)

  Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you have chills?

• Finding:

  Reports feeling "kind of tired"

  (Found)

  Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you have fatigue?

• Finding:

  Denies night sweats

  (Found)

  Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you have night sweats?

• Finding:

  Denies weight loss

  (Available)

  Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Has your weight changed?

• Finding:

  Denies appetite loss

  (Available)

  Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Have you lost your appetite?

• Finding:

  Asked about review of systems for HEENT

• Finding:

  Denies ear popping or crackling

  (Available)

  Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you hear any popping sounds?

• Finding:

  Reports history of frequent ear infections

  (Available)

  Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Have you ever had ear infections?

• Finding:

  Denies ear surgery or ear tubes

  (Available)

  Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Have you ever had surgery on your ears?

• Finding:

  Denies headaches

  (Found)

  Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you get headaches?

• Finding:

  Denies nosebleeds

  (Found)

  Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you have nosebleeds?

• Finding:

  Denies vision problems

  (Found)

  Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you have any problems with your vision?

• Finding:

  Denies dizziness

  (Found)

  Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you have any dizziness?

• Finding:

  Denies watery eyes

  (Available)

  Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you have watery eyes?

• Finding:

  Denies eye redness

  (Available)

  Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you have eye redness?

• Finding:

  Denies eye pain

  (Available)

  Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you have any eye pain?

• Finding:

  Denies sinus pain

  (Found)

  Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you have any sinus pain?

• Finding:

  Denies hearing problems

  (Found)

  Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you have any hearing problems?

• Finding:

  Asked about review of systems for respiratory

• Finding:

  Denies difficulty breathing

  (Found)

  Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you have difficulty breathing?

• Finding:

  Denies chest tightness

  (Available)

  Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you have chest tightness?

• Finding:

  Denies chest pain

  (Found)

  Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you have any chest pain?

• Finding:

  Denies history of inhaler use or breathing treatments

  (Available)

  Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Have you ever used an inhaler?

Objective Data Collection: 11.87 of 13 (91.31%)

• Correct
• Partially correct

• Incorrect
• Missed

Inspected eyes and orbital area 1 of 1 point Orbital Area (1/4 point)

• No visible abnormal findings
• Ptosis
• Eyelid edema
• Lesion
• Allergic shiners

Sclera (1/4 point)

• White
• Jaundice
• Injection
• Icterus

Conjunctiva (1/4 point)

• Moist and pink
• Pale
• Dry appearance
• Erythema
• Edema

Conjunctival Discharge (1/4 point)

• No discharge
• Clear, watery discharge
• Purulent discharge

Inspected nasal cavities 1 of 1 point Color (1/4 point)

• Pink
• Erythemic
• Bluish

Discharge (1/4 point)

• No discharge
• Clear discharge
• Bloody discharge
• Purulent discharge

Turbinate Patency (1/4 point)

• Patent
• Decreased patency
• Not patent

Observations (1/4 point)

• No additional visible abnormal findings
• Foreign body present
• Polyp
• Septum perforated
• Septum deviated
• Lesion

Inspected ears 0.8 of 1 point Right: Auditory Canal Color (No point)

• Pink
• Erythemic
• Pallor

Right: Tympanic Membrane Color (No point)

• Pearly gray
• Erythemic
• Opaque
• Yellow
• Not visible because of cerumen

Right: Tympanic Membrane Appearance (1/10 point)

• No visible abnormal findings
• Fluid observed
• Visible scars
• Bulging
• Perforation
• Retraction

Right: Cone Of Light (1/10 point)

• 5:00
• Cone of light distorted

Right: Discharge (1/10 point)

• No discharge
• Cerumen
• Clear discharge
• Bloody discharge
• Purulent discharge

Left: Auditory Canal Color (1/10 point)

• Pink
• Erythemic
• Pallor

Left: Tympanic Membrane Color (1/10 point)

• Pearly gray
• Erythemic
• Opaque
• Yellow
• Not visible because of cerumen

Left: Tympanic Membrane Appearance (1/10 point)

• No visible abnormal findings
• Fluid observed
• Visible scars
• Bulging
• Perforation
• Retraction

Left: Cone Of Light (1/10 point)

• 7:00
• Cone of light distorted

Left: Discharge (1/10 point)

• No discharge
• Cerumen
• Clear discharge
• Bloody discharge
• Purulent discharge

Inspected mouth and throat 0.4 of 1 point Oral Mucosa (1/5 point)

• Moist and pink
• Dry appearance
• Erythema

Tonsils (No point)

• No visible abnormal findings
• Edema
• Erythema

Posterior Oropharynx Color (No point)

• Pink
• Erythemic

Posterior Oropharynx Texture (No point)

• No abnormal findings
• Cobblestoning
• Exudate

Post Nasal Drip (1/5 point)

• No discharge
• Clear discharge
• Purulent discharge

Inspected neck 1 of 1 point Symmetry (1/2 point)

• Symmetric
• Asymmetric

Appearance (1/2 point)

• No visible abnormal findings
• Swelling
• Visible pulsation
• Visible mass
• Discoloration

Inspected chest 1 of 1 point Symmetry (1/2 point)

• Symmetric
• Asymmetric

Appearance (1/2 point)

• No visible abnormal findings
• Rash or lesion
• AP diameter abnormal Intercostal retraction while breathing
• Excessive use of accessory muscles while breathing
• Pectus excavatum
• Skin growths (freckles or moles)
• Evidence of skin trauma (scar, laceration, or bruising)

Palpated sinuses 1 of 1 point Frontal (1/2 point)

• None reported
• Tenderness reported

Maxillary (1/2 point)

• None reported
• Tenderness reported

Palpated lymph nodes 0.67 of 1 point Cervical (No point)

• No palpable nodes
• Palpable nodes on right side
• Palpable nodes on left side

Supraclavicular (1/3 point)

• No palpable nodes
• Palpable nodes on right side
• Palpable nodes on left side

Axillary (1/3 point)

• No palpable nodes
• Palpable nodes on right side
• Palpable nodes on left side

Palpated fremitus 1 of 1 point Symmetry (1/2 point)

• Equal bilaterally
• Unequal bilaterally

Vibration (1/2 point)

• Expected fremitus
• Decreased fremitus

Auscultated breath sounds 1 of 1 point Breath Sounds (1/3 point)

• Present in all areas
• Diminished in some areas
• Absent in some areas

Adventitious Sounds (1/3 point)

• No adventitious sounds
• Wheezing
• Fine crackles
• Stridor
• Rhonchi
• Rales

Location (1/3 point)

• All areas clear
• Adventitious sounds in anterior right upper lobe
• Adventitious sounds in anterior right middle lobe
• Adventitious sounds in anterior right lower lobe
• Adventitious sounds in anterior left upper lobe
• Adventitious sounds in anterior left lower lobe
• Adventitious sounds in posterior right upper lobe
• Adventitious sounds in posterior right lower lobe
• Adventitious sounds in posterior left upper lobe
• Adventitious sounds in posterior left lower lobe

Auscultated for bronchophony 1 of 1 point Bronchophony (1/1 point)

• Positive
• Negative

Auscultated heart sounds 1 of 1 point Heart Sounds (1/2 point)

• S1 and S2 audible
• S1, S2, and S3 audible
• S1, S2, and S4 audible
• S1, S2, S3, and S4 audible

Extra Heart Sounds (1/2 point)

• No extra sounds
• Gallops
• Murmur
• Friction rub
• Valve clicks

Percussed chest wall 1 of 1 point Observations (1/2 point)

• All areas resonant
• Some areas dull, some resonant
• Some areas hyperresonant, some resonant

Location (1/2 point)

• No areas of dullness
• Dullness, anterior right upper lobe
• Dullness, anterior right middle lobe
• Dullness, anterior right lower lobe
• Dullness, anterior left upper lobe
• Dullness, anterior left lower lobe
• Dullness, posterior right upper lobe
• Dullness, posterior right lower lobe
• Dullness, posterior left upper lobe
• Dullness, posterior left lower lobe

Education & Empathy : 4 of 5 (80.0%)

During the patient interview, there are a number of opportunities to provide patient education and empathy. The opportunities listed below are those identified by nursing experts to be of particular importance to this patient. A Model Statement is provided as an example of an appropriate response to each opportunity.

• Opportunities marked as Not Encountered are opportunities that were not elicited in the interview
• Opportunities marked as Not Followed Up are missed opportunities that were present in the interview, but where no statements were made
• Opportunities marked as Followed Up were followed up by students, and include the dialogue between student and patient

1 Symptoms Followed Up

	Description: Danny describes the symptoms that have been bothering him.
This is your avatar.	do you have fatigue	Question 12:40 AM MDT
Danny Rivera	Yeah, I feel kind of tired. I think it's because I couldn't sleep much at night. My cough kept me from falling asleep.
This is your avatar.	sorry to hear that	Empathize 12:40 AM MDT
Danny Rivera	Thank you.
	Model Statement: "I’m sorry your ear and your throat hurt. I’ll take a look and we’ll see if we can help you feel better."

2 Medications Followed Up

	Description: Danny describes the medication he was given for his cough.
This is your avatar.	what medicine do you take for the runny nose (Clarified to: Did you take medication for your runny nose?)	Question 12:42 AM MDT
Danny Rivera	I guess I don't do anything for my nose. I make sure to keep a tissue around so I can blow it, but it still keeps running. (Clarified to: if I took medication to treat my runny nose)
This is your avatar.	do you have headaches	Question 12:43 AM MDT
Danny Rivera	I don't usually get headaches.
This is your avatar.	do you get nose bleeds	Question 12:43 AM MDT
Danny Rivera	Just one time. Tony and I were kicking a ball at recess and I got hit in the nose.
This is your avatar.	sorry about that	Empathize 12:44 AM MDT
Danny Rivera	Thank you.
	Model Statement: "Thanks for telling me what you know about the medications you take. I can ask your mom or your abuela for more information."

3 Vitamins Followed Up

	Description: Danny describes taking vitamins.
This is your avatar.	do you take any vitamins	Question 12:18 AM MDT
Danny Rivera	Oh yeah, I take vitamins every day! The gummy dinosaur kind. I don't think I'm supposed to, but sometimes I sneak extra ones to be super healthy!
This is your avatar.	taking too much vitamins can cause other health issues	Educate 12:19 AM MDT
Danny Rivera	Oh, OK.
	Model Statement: "You’re right; taking vitamins can be good for you. However, sometimes taking too many vitamins can be bad for you. It’d be better if you don’t sneak extra vitamins -- just take the amount that your mom gives you."

4 Secondhand Smoke Not Followed Up

	Description: Danny describes exposure to secondhand smoke at home.
This is your avatar.	do you smoke	Question 12:11 AM MDT
Danny Rivera	No way! I know smoking is really bad--even for grown-ups. Papi smokes cigars sometimes. I don't like how they smell.
This is your avatar.	are you ever around cigarette smoke	Question 12:12 AM MDT
Danny Rivera	Well . . . sometimes Papi smokes cigars in the house and my mom has to tell him to go outside. I breathe it a little bit then, but it's not all the time or anything. I don't like how it smells.
This is your avatar.	have you done anything to treat your cough?	Question 12:12 AM MDT
	Model Statement: "That’s too bad your Papi smokes cigars at home. It sounds like it bothers you. Breathing in smoke isn’t very healthy, so it’s good to stay out rooms where you can smell cigar smoke."

5 Family History Followed Up

	Description: Danny describes what he knows about his family health history.
This is your avatar.	Thanks for telling what you know about you and family history. That was a great job	Question 02:02 AM MDT
Danny Rivera	My mom sometimes talks about her diabetes, cholesterol. . . Oh, and blood pressure. Papi talks about cholesterol too. He smokes too. I know that's bad.
This is your avatar.	That is too bad your papi smokes at home. secondhand smoking is bad for health. I can tell you bothers you a lot.	Empathize 02:04 AM MDT
Danny Rivera	Thank you.
	Model Statement: "Thanks for telling me what you know about your family history. You did a good job remembering."

Documentation / Electronic Health Record

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End of Program Competency Progress

The Competency Mapping feature allows you to track your progress against end of program competencies by uncovering early, intermediate, and end level benchmarks within Shadow Health assignments. Below you will find a breakdown of these benchmarks and explanations of high level domains, their associated competencies, measurable outcomes, and the scored items you have achieved throughout this assignment to progress each competency.

The information you see on this page reflects your progress within this assignment. This progress does not reflect your score for this assignment.

Domains	Competencies	Measurable Outcomes
Domains are the highest level category themes of knowledge, skills and attitudes which each competency works to progress. Each domain is split into Early, Intermediate and End levels of measurable outcomes.	Competencies are the knowledge, skills, and attitudes that are central to becoming a proficient health professional. As you progress through Shadow Health assignments, you are building competency in these key areas.	Measurable Outcomes are observable skills demonstrated as a result of an educational experience. Scored items in this assignment are mapped to outcomes. Each outcome is mapped to and progresses a specific competency.
Some Domains in this assignment Scientific Foundation Independent Practice Quality	Some Competencies in this assignment Provides Care as Primary Healthcare Provider to Patients Integrates Prior Knowledge Into Advanced Practice Nursing Role Addresses the Patient's Cultural and Spiritual Preferences, Values, and Beliefs When Providing Care	Some Outcomes in this assignment Identifies appropriate advanced healthcare assessments for individuals Demonstrates advanced practice procedures according to practice standards with supervision Conducts assessments accurately identifying normal and abnormal findings

Scientific Foundation

Domain Overview Competency Map 94.4% Domain Program Goal The domain of Scientific Foundation encompasses integrating established knowledge from relevant scientific fields into advanced patient care in a variety of healthcare settings. Early Intermediate End Early outcomes fall within the foundational level of a domain and demonstrate beginning knowledge of health care concepts. The Early bars below represent early domain level outcomes you have met in this assignment. Intermediate outcomes build upon the foundation of early outcomes and develop understanding of how to properly complete a task. The Intermediate bars below represent the middle domain level outcomes you have met in this assignment. End outcomes represent the highest level of proficiency and signify higher levels of wisdom and a deeper understanding of the reasoning behind actions. The End bars below represent the end domain level outcomes you have met in this assignment. Provides Care as Primary Healthcare Provider to Patients Early Intermediate End 94.4% N/A N/A Subjective Data Objective Data Correct Missed Partially Correct Incorrect Demonstrates advanced practice procedures according to practice standards with supervision Early Established chief complaint Conducts assessments accurately identifying normal and abnormal findings Early Followed up on ear pain Asked about throat symptoms Asked about relevant medical history Asked about ear symptoms Asked about character of cough Asked about contact with illnesses Followed up on nasal discharge Asked about relieving factors for cough Asked about nasal symptoms Asked about allergies Asked about frequency and duration of cough Asked about onset of cough Asked about aggravating factors for cough Identifies appropriate advanced healthcare assessments for individuals Early Auscultated breath sounds Auscultated for bronchophony Auscultated heart sounds Inspected chest Inspected ears Inspected eyes and orbital area Inspected mouth and throat Inspected neck Inspected nasal cavities Palpated fremitus Palpated lymph nodes Palpated sinuses Percussed chest wall Conducts assessments accurately identifying normal and abnormal findings Early Auscultated breath sounds Auscultated for bronchophony Auscultated heart sounds Inspected chest Inspected ears Inspected eyes and orbital area Inspected mouth and throat Inspected neck Inspected nasal cavities Palpated fremitus Palpated lymph nodes Palpated sinuses Percussed chest wall Integrates Prior Knowledge Into Advanced Practice Nursing Role Early Intermediate End 94.5% N/A N/A Subjective Data Objective Data Education & Empathy Correct Missed Partially Correct Incorrect Integrates knowledge from the humanities and sciences within the context of defined practice area Early Followed up on ear pain Asked about review of systems for respiratory Asked about home medications Asked about throat symptoms Established chief complaint Asked about relevant medical history Asked about review of systems for HEENT Asked about exposure to secondhand smoke Asked about ear symptoms Asked about character of cough Asked about contact with illnesses Followed up on nasal discharge Asked about relieving factors for cough Asked about constitutional health Asked about nasal symptoms Asked about allergies Asked about frequency and duration of cough Asked about onset of cough Followed up on cough medicine Asked about aggravating factors for cough Asked about living conditions Integrates knowledge from the humanities and sciences within the context of defined practice area Early Auscultated breath sounds Auscultated for bronchophony Auscultated heart sounds Inspected chest Inspected ears Inspected eyes and orbital area Inspected mouth and throat Inspected neck Inspected nasal cavities Palpated fremitus Palpated lymph nodes Palpated sinuses Percussed chest wall Integrates knowledge from the humanities and sciences within the context of defined practice area Early Symptoms Secondhand Smoke Medications Family History Vitamins

Independent Practice

Domain Overview Competency Map 88.2% Domain Program Goal The domain of Independent Practice encompasses the ability to design and manage advanced patient care while respecting the patient as an equal partner in their care. Early Intermediate End Early outcomes fall within the foundational level of a domain and demonstrate beginning knowledge of health care concepts. The Early bars below represent early domain level outcomes you have met in this assignment. Intermediate outcomes build upon the foundation of early outcomes and develop understanding of how to properly complete a task. The Intermediate bars below represent the middle domain level outcomes you have met in this assignment. End outcomes represent the highest level of proficiency and signify higher levels of wisdom and a deeper understanding of the reasoning behind actions. The End bars below represent the end domain level outcomes you have met in this assignment. Addresses the Patient's Cultural and Spiritual Preferences, Values, and Beliefs When Providing Care Early Intermediate End 66.7% N/A N/A Education & Empathy Correct Missed Partially Correct Incorrect Develops culturally sensitive patient and family education Early Secondhand Smoke Medications Vitamins Demonstrate Patient-Centered Care That Recognizes the Patient or Designee as a Full Partner in Decision Making Early Intermediate End 100% N/A N/A Education & Empathy Correct Missed Partially Correct Incorrect Takes actions that demonstrate empathy toward patient and family Early Symptoms Family History Demonstrate Competence in Clinical Decision Making Early Intermediate End 91.3% N/A N/A Objective Data Correct Missed Partially Correct Incorrect Identifies evidence-based standards of care Early Auscultated breath sounds Auscultated for bronchophony Auscultated heart sounds Inspected chest Inspected ears Inspected eyes and orbital area Inspected mouth and throat Inspected neck Inspected nasal cavities Palpated fremitus Palpated lymph nodes Palpated sinuses Percussed chest wall

Quality

Domain Overview Competency Map 97.8% Domain Program Goal The domain of Quality encompasses investigation of current practice processes, appraisal of best evidence, and integration of safety strategies into advanced patient care. Early Intermediate End Early outcomes fall within the foundational level of a domain and demonstrate beginning knowledge of health care concepts. The Early bars below represent early domain level outcomes you have met in this assignment. Intermediate outcomes build upon the foundation of early outcomes and develop understanding of how to properly complete a task. The Intermediate bars below represent the middle domain level outcomes you have met in this assignment. End outcomes represent the highest level of proficiency and signify higher levels of wisdom and a deeper understanding of the reasoning behind actions. The End bars below represent the end domain level outcomes you have met in this assignment. Determines Best Available Evidence for Clinical Practice Early Intermediate End 96.2% N/A N/A Subjective Data Objective Data Correct Missed Partially Correct Incorrect Adheres to standards of practice following clinical guidelines for the specific focus of advanced practice Early Followed up on ear pain Asked about review of systems for respiratory Asked about throat symptoms Asked about relevant medical history Asked about review of systems for HEENT Asked about exposure to secondhand smoke Asked about ear symptoms Asked about character of cough Asked about contact with illnesses Followed up on nasal discharge Asked about relieving factors for cough Asked about constitutional health Asked about nasal symptoms Asked about allergies Asked about frequency and duration of cough Asked about onset of cough Asked about aggravating factors for cough Adheres to standards of practice following clinical guidelines for the specific focus of advanced practice Early Auscultated breath sounds Auscultated for bronchophony Auscultated heart sounds Inspected chest Inspected ears Inspected eyes and orbital area Inspected mouth and throat Inspected neck Inspected nasal cavities Palpated fremitus Palpated lymph nodes Palpated sinuses Percussed chest wall Utilizes Safety Strategies That are Derived from Safety Principles and Safety Sciences Early Intermediate End 100% N/A N/A Subjective Data Correct Missed Partially Correct Incorrect Conduct medication reconciliation for all patients Early Asked about home medications Followed up on cough medicine Identifies risks to patients, self, and team members at an advanced practice level Early Followed up on ear pain Asked about review of systems for respiratory Asked about home medications Asked about throat symptoms Asked about relevant medical history Asked about review of systems for HEENT Asked about exposure to secondhand smoke Asked about ear symptoms Asked about character of cough Asked about contact with illnesses Followed up on nasal discharge Asked about relieving factors for cough Asked about constitutional health Asked about nasal symptoms Asked about allergies Asked about frequency and duration of cough Asked about onset of cough Followed up on cough medicine Asked about aggravating factors for cough Asked about living conditions

Population Health

Domain Overview Competency Map 100% Domain Program Goal The domain of Population Health encompasses big-picture care of populations through illness prevention, health policy advancement, community engagement, and promotion of health equity. Early Intermediate End Early outcomes fall within the foundational level of a domain and demonstrate beginning knowledge of health care concepts. The Early bars below represent early domain level outcomes you have met in this assignment. Intermediate outcomes build upon the foundation of early outcomes and develop understanding of how to properly complete a task. The Intermediate bars below represent the middle domain level outcomes you have met in this assignment. End outcomes represent the highest level of proficiency and signify higher levels of wisdom and a deeper understanding of the reasoning behind actions. The End bars below represent the end domain level outcomes you have met in this assignment. Advances Health Equity Early Intermediate End 100% N/A N/A Subjective Data Correct Missed Partially Correct Incorrect Assesses understanding of medically underserved communities and the impact on the community as a whole Early Asked about exposure to secondhand smoke Asked about living conditions Creates Successful Partnerships With Patients and Communities Early Intermediate End 100% N/A N/A Subjective Data Correct Missed Partially Correct Incorrect Identifies specific care considerations based on population cultural diversity Early Asked about exposure to secondhand smoke Asked about living conditions

Professionalism

Domain Overview Competency Map 80% Domain Program Goal The domain of Professionalism encompasses committing to continual development of professional identity as well as the concepts of accountability and safe practice. Early Intermediate End Early outcomes fall within the foundational level of a domain and demonstrate beginning knowledge of health care concepts. The Early bars below represent early domain level outcomes you have met in this assignment. Intermediate outcomes build upon the foundation of early outcomes and develop understanding of how to properly complete a task. The Intermediate bars below represent the middle domain level outcomes you have met in this assignment. End outcomes represent the highest level of proficiency and signify higher levels of wisdom and a deeper understanding of the reasoning behind actions. The End bars below represent the end domain level outcomes you have met in this assignment. Compliance with Relevant Laws, Policies, and Regulations Early Intermediate End 80% N/A N/A Education & Empathy Correct Missed Partially Correct Incorrect Demonstrates integrity and ethical behaviors consistent with advanced nursing practice Early Symptoms Secondhand Smoke Medications Family History Vitamins

Information Literacy

Domain Overview Competency Map 94.5% Domain Program Goal The domain of Technology and Information Literacy encompasses the ability to effectively utilize technology in the delivery of advanced patient care and the protection of patient privacy. Early Intermediate End Early outcomes fall within the foundational level of a domain and demonstrate beginning knowledge of health care concepts. The Early bars below represent early domain level outcomes you have met in this assignment. Intermediate outcomes build upon the foundation of early outcomes and develop understanding of how to properly complete a task. The Intermediate bars below represent the middle domain level outcomes you have met in this assignment. End outcomes represent the highest level of proficiency and signify higher levels of wisdom and a deeper understanding of the reasoning behind actions. The End bars below represent the end domain level outcomes you have met in this assignment. Uses Technology to Teach and Communicate with Patients, Families, and Colleagues Early Intermediate End 94.5% N/A N/A Subjective Data Objective Data Education & Empathy Correct Missed Partially Correct Incorrect Identifies strategies to communicate healthcare information clearly in oral and written form Early Followed up on ear pain Asked about review of systems for respiratory Asked about home medications Asked about throat symptoms Established chief complaint Asked about relevant medical history Asked about review of systems for HEENT Asked about exposure to secondhand smoke Asked about ear symptoms Asked about character of cough Asked about contact with illnesses Followed up on nasal discharge Asked about relieving factors for cough Asked about constitutional health Asked about nasal symptoms Asked about allergies Asked about frequency and duration of cough Asked about onset of cough Followed up on cough medicine Asked about aggravating factors for cough Asked about living conditions Documents assessment findings appropriately in EHR Early Auscultated breath sounds Auscultated for bronchophony Auscultated heart sounds Inspected chest Inspected ears Inspected eyes and orbital area Inspected mouth and throat Inspected neck Inspected nasal cavities Palpated fremitus Palpated lymph nodes Palpated sinuses Percussed chest wall Identifies strategies to communicate healthcare information clearly in oral and written form Early Symptoms Secondhand Smoke Medications Family History Vitamins

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