Digital Clinical Experience: Assessing the Heart, Lungs, and Peripheral Vascular System

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Name: NURS_6512_Week_7_DCE_Assignment_1_Rubric

Description: To complete the Shadow Health assignments, it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions and the physical assessment areas. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Weeks 1 and 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score.

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	Excellent	Good	Fair	Poor
Student DCE score (DCE percentages will be calculated automatically by Shadow Health after the assignment is completed.) Note: DCE Score - Do not round up on the DCE score.	Points: Points Range: 56 (56%) - 60 (60%) DCE score>93 Feedback:	Points: Points Range: 51 (51%) - 55 (55%) DCE Score 86-92 Feedback:	Points: Points Range: 46 (46%) - 50 (50%) DCE Score 80-85 Feedback:	Points: Points Range: 0 (0%) - 45 (45%) DCE Score <79 No DCE completed. Feedback:
Subjective Documentation in Provider Notes Subjective narrative documentation in Provider Notes is detailed and organized and includes: Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS) ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.	Points: Points Range: 16 (16%) - 20 (20%) Documentation is detailed and organized with all pertinent information noted in professional language. Documentation includes all pertinent documentation to include Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). Feedback:	Points: Points Range: 11 (11%) - 15 (15%) Documentation with sufficient details, some organization and some pertinent information noted in professional language. Documentation provides some of the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). Feedback:	Points: Points Range: 6 (6%) - 10 (10%) Documentation with inadequate details and/or organization; and inadequate pertinent information noted in professional language. Limited or/minimum documentation provided to analyze students critical thinking abilities for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). Feedback:	Points: Points Range: 0 (0%) - 5 (5%) Documentation lacks any details and/or organization; and does not provide pertinent information noted in professional language. No information is provided for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). or No documentation provided. Feedback:
Objective Documentation in Provider Notes - this is to be completed in Shadow Health Physical exam: Document in a systematic order starting from head-to-toe, include what you see, hear, and feel when doing your physical exam using medical terminology/jargon. Document all normal and abnormal exam findings. Do not use "WNL" or "normal". You only need to examine the systems that are pertinent to the CC, HPI, and History. Diagnostic result - Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1).	Points: Points Range: 16 (16%) - 20 (20%) Documentation detailed and organized with all abnormal and pertinent normal assessment information described in professional language. Each system assessed is clearly documented with measurable details of the exam. Feedback:	Points: Points Range: 11 (11%) - 15 (15%) Documentation with sufficient details and some organization; some abnormal and some normal assessment information described in mostly professional language. Each system assessed is somewhat clearly documented with measurable details of the exam. Feedback:	Points: Points Range: 6 (6%) - 10 (10%) Documentation with inadequate details and/or organization; inadequate identification of abnormal and pertinent normal assessment information described; inadequate use of professional language. Each system assessed is minimally or is not clearly documented with measurable details of the exam. Feedback:	Points: Points Range: 0 (0%) - 5 (5%) Documentation with no details and/or organization; no identification of abnormal and pertinent normal assessment information described; no use of professional language. None of the systems are assessed, no documentation of details of the exam. or No documentation provided. Feedback:

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Student DCE score (DCE percentages will be calculated automatically by Shadow Health after the assignment is completed.) Note: DCE Score - Do not round up on the DCE score.--

Levels of Achievement: Excellent 56 (56%) - 60 (60%) DCE score>93 Good 51 (51%) - 55 (55%) DCE Score 86-92 Fair 46 (46%) - 50 (50%) DCE Score 80-85 Poor 0 (0%) - 45 (45%) DCE Score <79 No DCE completed. Feedback:

Subjective Documentation in Provider Notes Subjective narrative documentation in Provider Notes is detailed and organized and includes: Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS) ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.--

Levels of Achievement: Excellent 16 (16%) - 20 (20%) Documentation is detailed and organized with all pertinent information noted in professional language. Documentation includes all pertinent documentation to include Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). Good 11 (11%) - 15 (15%) Documentation with sufficient details, some organization and some pertinent information noted in professional language. Documentation provides some of the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). Fair 6 (6%) - 10 (10%) Documentation with inadequate details and/or organization; and inadequate pertinent information noted in professional language. Limited or/minimum documentation provided to analyze students critical thinking abilities for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). Poor 0 (0%) - 5 (5%) Documentation lacks any details and/or organization; and does not provide pertinent information noted in professional language. No information is provided for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). or No documentation provided. Feedback:

Objective Documentation in Provider Notes - this is to be completed in Shadow Health Physical exam: Document in a systematic order starting from head-to-toe, include what you see, hear, and feel when doing your physical exam using medical terminology/jargon. Document all normal and abnormal exam findings. Do not use "WNL" or "normal". You only need to examine the systems that are pertinent to the CC, HPI, and History. Diagnostic result - Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1).--

Levels of Achievement: Excellent 16 (16%) - 20 (20%) Documentation detailed and organized with all abnormal and pertinent normal assessment information described in professional language. Each system assessed is clearly documented with measurable details of the exam. Good 11 (11%) - 15 (15%) Documentation with sufficient details and some organization; some abnormal and some normal assessment information described in mostly professional language. Each system assessed is somewhat clearly documented with measurable details of the exam. Fair 6 (6%) - 10 (10%) Documentation with inadequate details and/or organization; inadequate identification of abnormal and pertinent normal assessment information described; inadequate use of professional language. Each system assessed is minimally or is not clearly documented with measurable details of the exam. Poor 0 (0%) - 5 (5%) Documentation with no details and/or organization; no identification of abnormal and pertinent normal assessment information described; no use of professional language. None of the systems are assessed, no documentation of details of the exam. or No documentation provided. Feedback:

Total Points: 100

Name: NURS_6512_Week_7_DCE_Assignment_1_Rubric

Description: To complete the Shadow Health assignments, it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions and the physical assessment areas. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Weeks 1 and 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score.