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NURS_6512_Module2_AssignmentTemplate.docx
NURS_6512_ComprehensiveHealthHistory_ReferenceSheet.pdf
InstrucWk4Assgnmt.docx

NURS_6512_Module2_AssignmentTemplate.docx

NURS 6512

Week 4 Assignment Template

Comprehensive Health History and Physical Examination Template

Part I: Comprehensive Health History (Subjective Data Only)

Subjective Data

Chief Complaint (CC):

History of Present Illness (HPI):

Past Medical History (PMH):

Surgical History (PSH):

Medications:

Allergies:

Preventive Health:

Social History:

Review of Systems (ROS) (Subjective Data Only – Patient-Reported Symptoms):

General:

Skin:

HEENT:

Cardiac:

Respiratory:

Gastrointestinal (GI):

Genitourinary (GU):

Musculoskeletal (MSK):

Neurologic:

Psychiatric:

Endocrine:

Hematologic/Lymphatic/Immune:

Part II: Focused Physical Examination (Objective Data Only)

Physical Examination (Objective Data Only – Do NOT include subjective statements):

General:

Skin:

Head:

Eyes:

Ears:

Nose:

Mouth/Throat:

Neck:

Cardiac:

Lungs:

Abdomen:

Genitourinary (GU):

Musculoskeletal:

Lower Extremities:

Neurologic:

Part III: Reflection

Part III, Section 1: Subjective vs. Objective Distinction

1. Identify two examples where it may have been challenging to separate subjective from objective data.

2. Explain how you ensured that patient-reported symptoms remained in the history section.

3. Explain how you ensured that only observable or measurable findings were included in the physical exam section.

Part III, Section 2: Additional Assessment Questions

Identify 2–3 additional questions you would ask to strengthen your subjective assessment.

For each question: • State the question • Briefly explain why it is important • Describe how the response could guide your focused physical examination

Part III, Section 3: Professional Growth

Identify one area of your assessment skills that you would like to improve (e.g., documenting vesicular lesions, describing rash morphology, lymph node assessment). Briefly explain how you plan to strengthen that skill.

References

List 3–5 peer-reviewed references, less than 5 Years Old. Cite all sources in APA format.

NURS_6512_ComprehensiveHealthHistory_ReferenceSheet.pdf

NURS 6512: Comprehensive Health History Reference Sheet

⚠ Reminder: The health history includes **subjective data only** — information provided by the patient about their symptoms, perceptions, and experiences. Objective findings belong in the physical exam section.

Chief Complaint (CC)

• State the patient’s main reason for visit — concise and focused. • Use the patient’s own words in quotes (1–2 words or one short sentence). • Example: “Sore throat for two days.” or “Shortness of breath.”

History of Present Illness (HPI) – OLDCARTS + Pertinent History

• Use OLDCARTS to gather data, then synthesize into a cohesive paragraph written in complete sentences. • Avoid bullet points. Tell the story of the symptom(s) using the data you collected. • O – Onset: When did it start? • L – Location: Where is it? Does it radiate? • D – Duration: Constant or intermittent? • C – Character: Describe the quality (sharp, dull, throbbing). • A – Aggravating factors: What makes it worse? • R – Relieving factors: What makes it better? • T – Timing: Pattern, frequency, time of day. • S – Severity: 0–10 pain scale or functional impact. • Include associated symptoms and pertinent negatives (important symptoms the patient denies). • Incorporate pertinent history such as recent illness, exposures, travel, medications tried, previous episodes, or related chronic conditions. • Example: The HPI should read as a full paragraph that flows logically and reflects critical thinking — not as a list of OLDCARTS items.

Past Medical History (PMH)

• Chronic illnesses (HTN, DM, asthma, etc.) • Childhood illnesses (if relevant) • Hospitalizations and psychiatric history

Surgical History (PSH)

• List all surgeries/procedures with year, indication, and complications

Medications

• List all: prescription, OTC, herbal, and supplements • Include name, dose, route, frequency, indication • Note adherence and side effects

Allergies

• Drug, food, environmental — include reaction type (rash, anaphylaxis, etc.) • Document tolerated alternatives if known

Preventive Health

• Immunizations: Flu, COVID-19, Tdap, shingles, pneumococcal • Screenings: Pap, mammogram, colonoscopy, lipid, glucose, DEXA • Risk factors: Diet, exercise, safety, sexual health, sleep, stress, dental, vision

Social History

• Tobacco: Type, amount, duration, quit attempts • Alcohol: Type, frequency, quantity (CAGE if indicated) • Substance use: Illicit or prescription misuse • Occupation: Exposures, stress, satisfaction • Living situation & support system • Safety: IPV, firearms, seatbelt use • Social Determinants of Health (SDOH): Housing, food, transport, access, finances

Review of Systems (ROS)

These are subjective symptoms that the patient reports. No objective exam findings should be included here.

• General: Fever, chills, weight change, fatigue • Skin: Rashes, lesions, itching • HEENT: Vision, hearing, congestion, sore throat • Cardiac: Chest pain, palpitations, edema • Respiratory: Cough, SOB, wheezing • GI: N/V/D, constipation, pain, appetite • GU: Dysuria, frequency, hematuria • MSK: Joint pain, stiffness, weakness • Neuro: Headache, dizziness, numbness, seizures • Psych: Mood, anxiety, sleep • Endo: Heat/cold intolerance, polyuria/polydipsia • Heme: Easy bruising/bleeding

InstrucWk4Assgnmt.docx

The Assignment

Based on the case, complete document a comprehensive health history (subjective data only) and a focused physical examination (objective data only).

Do NOT provide:

· A diagnosis

· A differential diagnosis list

· A treatment plan

· Prescriptions

· Patient education

This assignment evaluates assessment and documentation skills only.

Expand the health history and focused physical examination results as appropriate by identifying and documenting expected findings. You may include your own version of history sections as you see fit. In other words, you can formulate your own health history and objective data of the patient as long as it is properly documented.

Part I: Comprehensive Health History (Subjective Data Only)

Reminder: The health history includes only information provided by the patient. It should not include physical exam findings.

You must:

· Expand the HPI using OLDCARTS

· Write the HPI as a cohesive paragraph (not bullet points)

· Include complete PMH, PSH, medications, allergies, preventive health, social history, and SDOH

· Complete a comprehensive or focused ROS (subjective only)

Reminder: The physical exam includes only what the clinician observes, palpates, percusses, or auscultates.

You must:

· Perform and document a focused examination appropriate to the chief complaint,

· Determine and document what objective findings you would expect to assess and record based on your clinical reasoning.

Documentation Expectations

You must:

· Clearly separate subjective and objective data

· Avoid including patient-reported symptoms in the physical exam section

· Avoid including exam findings in the history section

· Use professional medical terminology

· Demonstrate logical organization

· Align examination scope with the chief complaint

Evidence-Based Practice Requirement

Your documentation must incorporate a minimum of three, evidence-based scholarly references published within the last five years (≤ 5 years old). Cite all sources in APA format.

References must support:

· Clinical assessment of integumentary complaints

· Focused skin examination principles

· Any portion of the reflection section

Acceptable Sources:

· Peer-reviewed journal articles

· CDC clinical guidance

· IDSA guidelines

· Advanced practice nursing scholarly texts

· WHO clinical documents

Unacceptable Sources:

· Patient education websites (e.g., Mayo Clinic, Cleveland Clinic, WebMD, Healthline)

· Wikipedia

· Blogs or commercial health sites

All references must be cited in APA format.

After completing your comprehensive health history and focused physical examination, submit a reflection addressing the reflection prompts in the assignment template. This reflection is designed to help you strengthen your ability to clearly separate subjective and objective findings while performing an integumentary assessment. NURS_6512_Module2_Assignment_Rubric

NURS_6512_Module2_Assignment_Rubric
Criteria	Ratings	Pts
This criterion is linked to a Learning OutcomePart I: Comprehensive Health History (Subjective Data Only)... Demonstrates accurate and complete documentation of patient comprehensive health history (subjective data only).	25 to >22.35 ptsExcellentProvides accurate and complete documentation of patient comprehensive health history (subjective data only). 22.35 to >19.85 ptsGoodProvides a mostly accurate and complete patient comprehensive health history (subjective data only); may contain some minor errors. 19.85 to >0 ptsPoorDoes not provide documentation of patient health history (subjective data only); documentation is inaccurate and/or incomplete.	25 pts
This criterion is linked to a Learning OutcomePart II: Focused Physical Examination (Objective Data Only)... Demonstrates accurate and complete documentation of patient focused physical examination (objective data only).	25 to >22.35 ptsExcellentProvides accurate and complete documentation of patient focused physical examination (objective data only). 22.35 to >19.85 ptsGoodProvides a complete, mostly accurate documentation of patient focused physical examination (objective data only); may contain some minor errors. 19.85 to >0 ptsPoorDoes not provide documentation of patient focused physical examination (objective data only); data provided is inaccurate and/or incomplete.	25 pts
This criterion is linked to a Learning OutcomePart III: Reflection Section 1: Subjective vs. Objective Distinction...Identify two examples where it may have been challenging to separate subjective from objective data; Explain how you ensured that patient-reported symptoms remained in the history section; Explain how you ensured that only observable or measurable findings were included in the physical exam section.	15 to >13.41 ptsExcellentProvides two fully developed examples of situations that posed a challenge separating subjective and objective data... Fully explains how they ensured that patient-reported symptoms remained in the history section... Fully explains how they ensured that only observable or measurable findings were included in the physical exam section. 13.41 to >11.91 ptsGoodProvides two adequately developed examples of situations that posed a challenge separating subjective and objective data... Adequately explains how they ensured that patient-reported symptoms remained in the history section... Adequately explains how they ensured that only observable or measurable findings were included in the physical exam section. 11.91 to >0 ptsPoorDoes not provide examples of situations that posed a challenge separating subjective and objective data; explanations are unclear or incomplete.	15 pts
This criterion is linked to a Learning OutcomePart III: Reflection Section 2: Additional Assessment Questions... Identify 2–3 additional questions you would ask to strengthen your subjective assessment.... For each question: State the question; Briefly explain why it is important; Describe how the response could guide your focused physical examination	10 to >8.94 ptsExcellentIdentifies 2–3 additional questions they would ask to strengthen their subjective assessment... Provides a fully developed explanation of why the question is important... Provides a fully developed description of how the response could guide their focused examination. 8.94 to >7.94 ptsGoodIdentifies 2–3 additional questions they would ask to strengthen their subjective assessment... Provides an adequately developed explanation of why the question is important... Provides an adequately developed description of how the response could guide their focused examination. 7.94 to >0 ptsPoorDoes not identify 2–3 additional questions they would ask to strengthen their subjective assessment; the questions provided are unclear, inaccurate, or incomplete.	10 pts
This criterion is linked to a Learning OutcomePart III: Reflection... Section 3: Professional Growth... Identify one area of your assessment skills that you would like to improve (e.g., documenting vesicular lesions, describing rash morphology, lymph node assessment). Briefly explain how you plan to strengthen that skill.	10 to >8.94 ptsExcellentIdentifies one area of their assessment skills they would like to improve... Provides a fully developed explanations of how they plan to strengthen that skill. 8.94 to >7.94 ptsGoodIdentifies one area of their assessment skills they would like to improve... Provides an adequately developed explanations of how they plan to strengthen that skill. 7.94 to >0 ptsPoorDoes not identify one area of assessment skills they would like to improve; explanation is unclear, inaccurate, or incomplete.	10 pts
This criterion is linked to a Learning OutcomeUses at least 3 scholarly resources that are less than 5 years old.	5 to >4.46 ptsExcellentUses 3 peer-reviewed scholarly sources published within the last 5 years. 4.46 to >3.96 ptsGoodUses 2 peer-reviewed scholarly sources published within the last 5 years. 3.96 to >3.46 ptsFairUses 1 peer-reviewed scholarly source published within the last 5 years. 3.46 to >0 ptsPoorDoes not use peer-reviewed scholarly sources or sources used are older than 5 years.	5 pts
This criterion is linked to a Learning OutcomeSource Attribution and APA Formatting	5 to >4.46 ptsExcellentAll sources are cited in APA format without any errors. 4.46 to >3.96 ptsGoodAll sources are cited in APA format with some minor errors. 3.96 to >3.46 ptsFairAll sources are cited with frequent APA formatting errors. 3.46 to >0 ptsPoorMissing source citations and/or minimal adherence to APA formatting rules.	5 pts
This criterion is linked to a Learning OutcomeGrammar, Mechanics, and Punctuation	5 to >4.46 ptsExcellentCorrect grammar, spelling, and punctuation with no errors. 4.46 to >3.96 ptsGoodCorrect grammar, spelling, and punctuation with few errors. 3.96 to >3.46 ptsFairCorrect grammar, spelling, and punctuation with frequent errors. 3.46 to >0 ptsPoorFrequent errors in grammar, spelling, and punctuation that interfere with comprehension.	5 pts

Total Points: 100

InstrucWk4Assgnmt.docx

The Assignment

Based on the case, complete document a comprehensive health history (subjective data only) and a focused physical examination (objective data only).

Do NOT provide:

· A diagnosis

· A differential diagnosis list

· A treatment plan

· Prescriptions

· Patient education

This assignment evaluates assessment and documentation skills only.

Part I: Comprehensive Health History (Subjective Data Only)

Reminder: The health history includes only information provided by the patient. It should not include physical exam findings.

You must:

· Expand the HPI using OLDCARTS

· Write the HPI as a cohesive paragraph (not bullet points)

· Include complete PMH, PSH, medications, allergies, preventive health, social history, and SDOH

· Complete a comprehensive or focused ROS (subjective only)

Reminder: The physical exam includes only what the clinician observes, palpates, percusses, or auscultates.

You must:

· Perform and document a focused examination appropriate to the chief complaint,

· Determine and document what objective findings you would expect to assess and record based on your clinical reasoning.

Documentation Expectations

You must:

· Clearly separate subjective and objective data

· Avoid including patient-reported symptoms in the physical exam section

· Avoid including exam findings in the history section

· Use professional medical terminology

· Demonstrate logical organization

· Align examination scope with the chief complaint

Evidence-Based Practice Requirement

Your documentation must incorporate a minimum of three, evidence-based scholarly references published within the last five years (≤ 5 years old). Cite all sources in APA format.

References must support:

· Clinical assessment of integumentary complaints

· Focused skin examination principles

· Any portion of the reflection section

Acceptable Sources:

· Peer-reviewed journal articles

· CDC clinical guidance

· IDSA guidelines

· Advanced practice nursing scholarly texts

· WHO clinical documents

Unacceptable Sources:

· Patient education websites (e.g., Mayo Clinic, Cleveland Clinic, WebMD, Healthline)

· Wikipedia

· Blogs or commercial health sites

All references must be cited in APA format.

NURS_6512_Module2_Assignment_Rubric
Criteria	Ratings	Pts
This criterion is linked to a Learning OutcomePart I: Comprehensive Health History (Subjective Data Only)... Demonstrates accurate and complete documentation of patient comprehensive health history (subjective data only).	25 to >22.35 ptsExcellentProvides accurate and complete documentation of patient comprehensive health history (subjective data only). 22.35 to >19.85 ptsGoodProvides a mostly accurate and complete patient comprehensive health history (subjective data only); may contain some minor errors. 19.85 to >0 ptsPoorDoes not provide documentation of patient health history (subjective data only); documentation is inaccurate and/or incomplete.	25 pts
This criterion is linked to a Learning OutcomePart II: Focused Physical Examination (Objective Data Only)... Demonstrates accurate and complete documentation of patient focused physical examination (objective data only).	25 to >22.35 ptsExcellentProvides accurate and complete documentation of patient focused physical examination (objective data only). 22.35 to >19.85 ptsGoodProvides a complete, mostly accurate documentation of patient focused physical examination (objective data only); may contain some minor errors. 19.85 to >0 ptsPoorDoes not provide documentation of patient focused physical examination (objective data only); data provided is inaccurate and/or incomplete.	25 pts
This criterion is linked to a Learning OutcomePart III: Reflection Section 1: Subjective vs. Objective Distinction...Identify two examples where it may have been challenging to separate subjective from objective data; Explain how you ensured that patient-reported symptoms remained in the history section; Explain how you ensured that only observable or measurable findings were included in the physical exam section.	15 to >13.41 ptsExcellentProvides two fully developed examples of situations that posed a challenge separating subjective and objective data... Fully explains how they ensured that patient-reported symptoms remained in the history section... Fully explains how they ensured that only observable or measurable findings were included in the physical exam section. 13.41 to >11.91 ptsGoodProvides two adequately developed examples of situations that posed a challenge separating subjective and objective data... Adequately explains how they ensured that patient-reported symptoms remained in the history section... Adequately explains how they ensured that only observable or measurable findings were included in the physical exam section. 11.91 to >0 ptsPoorDoes not provide examples of situations that posed a challenge separating subjective and objective data; explanations are unclear or incomplete.	15 pts
This criterion is linked to a Learning OutcomePart III: Reflection Section 2: Additional Assessment Questions... Identify 2–3 additional questions you would ask to strengthen your subjective assessment.... For each question: State the question; Briefly explain why it is important; Describe how the response could guide your focused physical examination	10 to >8.94 ptsExcellentIdentifies 2–3 additional questions they would ask to strengthen their subjective assessment... Provides a fully developed explanation of why the question is important... Provides a fully developed description of how the response could guide their focused examination. 8.94 to >7.94 ptsGoodIdentifies 2–3 additional questions they would ask to strengthen their subjective assessment... Provides an adequately developed explanation of why the question is important... Provides an adequately developed description of how the response could guide their focused examination. 7.94 to >0 ptsPoorDoes not identify 2–3 additional questions they would ask to strengthen their subjective assessment; the questions provided are unclear, inaccurate, or incomplete.	10 pts
This criterion is linked to a Learning OutcomePart III: Reflection... Section 3: Professional Growth... Identify one area of your assessment skills that you would like to improve (e.g., documenting vesicular lesions, describing rash morphology, lymph node assessment). Briefly explain how you plan to strengthen that skill.	10 to >8.94 ptsExcellentIdentifies one area of their assessment skills they would like to improve... Provides a fully developed explanations of how they plan to strengthen that skill. 8.94 to >7.94 ptsGoodIdentifies one area of their assessment skills they would like to improve... Provides an adequately developed explanations of how they plan to strengthen that skill. 7.94 to >0 ptsPoorDoes not identify one area of assessment skills they would like to improve; explanation is unclear, inaccurate, or incomplete.	10 pts
This criterion is linked to a Learning OutcomeUses at least 3 scholarly resources that are less than 5 years old.	5 to >4.46 ptsExcellentUses 3 peer-reviewed scholarly sources published within the last 5 years. 4.46 to >3.96 ptsGoodUses 2 peer-reviewed scholarly sources published within the last 5 years. 3.96 to >3.46 ptsFairUses 1 peer-reviewed scholarly source published within the last 5 years. 3.46 to >0 ptsPoorDoes not use peer-reviewed scholarly sources or sources used are older than 5 years.	5 pts
This criterion is linked to a Learning OutcomeSource Attribution and APA Formatting	5 to >4.46 ptsExcellentAll sources are cited in APA format without any errors. 4.46 to >3.96 ptsGoodAll sources are cited in APA format with some minor errors. 3.96 to >3.46 ptsFairAll sources are cited with frequent APA formatting errors. 3.46 to >0 ptsPoorMissing source citations and/or minimal adherence to APA formatting rules.	5 pts
This criterion is linked to a Learning OutcomeGrammar, Mechanics, and Punctuation	5 to >4.46 ptsExcellentCorrect grammar, spelling, and punctuation with no errors. 4.46 to >3.96 ptsGoodCorrect grammar, spelling, and punctuation with few errors. 3.96 to >3.46 ptsFairCorrect grammar, spelling, and punctuation with frequent errors. 3.46 to >0 ptsPoorFrequent errors in grammar, spelling, and punctuation that interfere with comprehension.	5 pts

Total Points: 100

NURS_6512_Module2_AssignmentTemplate.docx

NURS 6512

Week 4 Assignment Template

Comprehensive Health History and Physical Examination Template

Part I: Comprehensive Health History (Subjective Data Only)

Subjective Data

Chief Complaint (CC):

History of Present Illness (HPI):

Past Medical History (PMH):

Surgical History (PSH):

Medications:

Allergies:

Preventive Health:

Social History:

Review of Systems (ROS) (Subjective Data Only – Patient-Reported Symptoms):

General:

Skin:

HEENT:

Cardiac:

Respiratory:

Gastrointestinal (GI):

Genitourinary (GU):

Musculoskeletal (MSK):

Neurologic:

Psychiatric:

Endocrine:

Hematologic/Lymphatic/Immune:

Part II: Focused Physical Examination (Objective Data Only)

Physical Examination (Objective Data Only – Do NOT include subjective statements):

General:

Skin:

Head:

Eyes:

Ears:

Nose:

Mouth/Throat:

Neck:

Cardiac:

Lungs:

Abdomen:

Genitourinary (GU):

Musculoskeletal:

Lower Extremities:

Neurologic:

Part III: Reflection

Part III, Section 1: Subjective vs. Objective Distinction

1. Identify two examples where it may have been challenging to separate subjective from objective data.

2. Explain how you ensured that patient-reported symptoms remained in the history section.

3. Explain how you ensured that only observable or measurable findings were included in the physical exam section.

Part III, Section 2: Additional Assessment Questions

Identify 2–3 additional questions you would ask to strengthen your subjective assessment.

For each question: • State the question • Briefly explain why it is important • Describe how the response could guide your focused physical examination

Part III, Section 3: Professional Growth

References

List 3–5 peer-reviewed references, less than 5 Years Old. Cite all sources in APA format.

NURS_6512_ComprehensiveHealthHistory_ReferenceSheet.pdf

NURS 6512: Comprehensive Health History Reference Sheet

Chief Complaint (CC)

History of Present Illness (HPI) – OLDCARTS + Pertinent History

Past Medical History (PMH)

• Chronic illnesses (HTN, DM, asthma, etc.) • Childhood illnesses (if relevant) • Hospitalizations and psychiatric history

Surgical History (PSH)

• List all surgeries/procedures with year, indication, and complications

Medications

• List all: prescription, OTC, herbal, and supplements • Include name, dose, route, frequency, indication • Note adherence and side effects

Allergies

• Drug, food, environmental — include reaction type (rash, anaphylaxis, etc.) • Document tolerated alternatives if known

Preventive Health

Social History

Review of Systems (ROS)

These are subjective symptoms that the patient reports. No objective exam findings should be included here.

InstrucWk4Assgnmt.docx

The Assignment

Based on the case, complete document a comprehensive health history (subjective data only) and a focused physical examination (objective data only).

Do NOT provide:

· A diagnosis

· A differential diagnosis list

· A treatment plan

· Prescriptions

· Patient education

This assignment evaluates assessment and documentation skills only.

Part I: Comprehensive Health History (Subjective Data Only)

Reminder: The health history includes only information provided by the patient. It should not include physical exam findings.

You must:

· Expand the HPI using OLDCARTS

· Write the HPI as a cohesive paragraph (not bullet points)

· Include complete PMH, PSH, medications, allergies, preventive health, social history, and SDOH

· Complete a comprehensive or focused ROS (subjective only)

Reminder: The physical exam includes only what the clinician observes, palpates, percusses, or auscultates.

You must:

· Perform and document a focused examination appropriate to the chief complaint,

· Determine and document what objective findings you would expect to assess and record based on your clinical reasoning.

Documentation Expectations

You must:

· Clearly separate subjective and objective data

· Avoid including patient-reported symptoms in the physical exam section

· Avoid including exam findings in the history section

· Use professional medical terminology

· Demonstrate logical organization

· Align examination scope with the chief complaint

Evidence-Based Practice Requirement

Your documentation must incorporate a minimum of three, evidence-based scholarly references published within the last five years (≤ 5 years old). Cite all sources in APA format.

References must support:

· Clinical assessment of integumentary complaints

· Focused skin examination principles

· Any portion of the reflection section

Acceptable Sources:

· Peer-reviewed journal articles

· CDC clinical guidance

· IDSA guidelines

· Advanced practice nursing scholarly texts

· WHO clinical documents

Unacceptable Sources:

· Patient education websites (e.g., Mayo Clinic, Cleveland Clinic, WebMD, Healthline)

· Wikipedia

· Blogs or commercial health sites

All references must be cited in APA format.

NURS_6512_Module2_Assignment_Rubric
Criteria	Ratings	Pts
This criterion is linked to a Learning OutcomePart I: Comprehensive Health History (Subjective Data Only)... Demonstrates accurate and complete documentation of patient comprehensive health history (subjective data only).	25 to >22.35 ptsExcellentProvides accurate and complete documentation of patient comprehensive health history (subjective data only). 22.35 to >19.85 ptsGoodProvides a mostly accurate and complete patient comprehensive health history (subjective data only); may contain some minor errors. 19.85 to >0 ptsPoorDoes not provide documentation of patient health history (subjective data only); documentation is inaccurate and/or incomplete.	25 pts
This criterion is linked to a Learning OutcomePart II: Focused Physical Examination (Objective Data Only)... Demonstrates accurate and complete documentation of patient focused physical examination (objective data only).	25 to >22.35 ptsExcellentProvides accurate and complete documentation of patient focused physical examination (objective data only). 22.35 to >19.85 ptsGoodProvides a complete, mostly accurate documentation of patient focused physical examination (objective data only); may contain some minor errors. 19.85 to >0 ptsPoorDoes not provide documentation of patient focused physical examination (objective data only); data provided is inaccurate and/or incomplete.	25 pts
This criterion is linked to a Learning OutcomePart III: Reflection Section 1: Subjective vs. Objective Distinction...Identify two examples where it may have been challenging to separate subjective from objective data; Explain how you ensured that patient-reported symptoms remained in the history section; Explain how you ensured that only observable or measurable findings were included in the physical exam section.	15 to >13.41 ptsExcellentProvides two fully developed examples of situations that posed a challenge separating subjective and objective data... Fully explains how they ensured that patient-reported symptoms remained in the history section... Fully explains how they ensured that only observable or measurable findings were included in the physical exam section. 13.41 to >11.91 ptsGoodProvides two adequately developed examples of situations that posed a challenge separating subjective and objective data... Adequately explains how they ensured that patient-reported symptoms remained in the history section... Adequately explains how they ensured that only observable or measurable findings were included in the physical exam section. 11.91 to >0 ptsPoorDoes not provide examples of situations that posed a challenge separating subjective and objective data; explanations are unclear or incomplete.	15 pts
This criterion is linked to a Learning OutcomePart III: Reflection Section 2: Additional Assessment Questions... Identify 2–3 additional questions you would ask to strengthen your subjective assessment.... For each question: State the question; Briefly explain why it is important; Describe how the response could guide your focused physical examination	10 to >8.94 ptsExcellentIdentifies 2–3 additional questions they would ask to strengthen their subjective assessment... Provides a fully developed explanation of why the question is important... Provides a fully developed description of how the response could guide their focused examination. 8.94 to >7.94 ptsGoodIdentifies 2–3 additional questions they would ask to strengthen their subjective assessment... Provides an adequately developed explanation of why the question is important... Provides an adequately developed description of how the response could guide their focused examination. 7.94 to >0 ptsPoorDoes not identify 2–3 additional questions they would ask to strengthen their subjective assessment; the questions provided are unclear, inaccurate, or incomplete.	10 pts
This criterion is linked to a Learning OutcomePart III: Reflection... Section 3: Professional Growth... Identify one area of your assessment skills that you would like to improve (e.g., documenting vesicular lesions, describing rash morphology, lymph node assessment). Briefly explain how you plan to strengthen that skill.	10 to >8.94 ptsExcellentIdentifies one area of their assessment skills they would like to improve... Provides a fully developed explanations of how they plan to strengthen that skill. 8.94 to >7.94 ptsGoodIdentifies one area of their assessment skills they would like to improve... Provides an adequately developed explanations of how they plan to strengthen that skill. 7.94 to >0 ptsPoorDoes not identify one area of assessment skills they would like to improve; explanation is unclear, inaccurate, or incomplete.	10 pts
This criterion is linked to a Learning OutcomeUses at least 3 scholarly resources that are less than 5 years old.	5 to >4.46 ptsExcellentUses 3 peer-reviewed scholarly sources published within the last 5 years. 4.46 to >3.96 ptsGoodUses 2 peer-reviewed scholarly sources published within the last 5 years. 3.96 to >3.46 ptsFairUses 1 peer-reviewed scholarly source published within the last 5 years. 3.46 to >0 ptsPoorDoes not use peer-reviewed scholarly sources or sources used are older than 5 years.	5 pts
This criterion is linked to a Learning OutcomeSource Attribution and APA Formatting	5 to >4.46 ptsExcellentAll sources are cited in APA format without any errors. 4.46 to >3.96 ptsGoodAll sources are cited in APA format with some minor errors. 3.96 to >3.46 ptsFairAll sources are cited with frequent APA formatting errors. 3.46 to >0 ptsPoorMissing source citations and/or minimal adherence to APA formatting rules.	5 pts
This criterion is linked to a Learning OutcomeGrammar, Mechanics, and Punctuation	5 to >4.46 ptsExcellentCorrect grammar, spelling, and punctuation with no errors. 4.46 to >3.96 ptsGoodCorrect grammar, spelling, and punctuation with few errors. 3.96 to >3.46 ptsFairCorrect grammar, spelling, and punctuation with frequent errors. 3.46 to >0 ptsPoorFrequent errors in grammar, spelling, and punctuation that interfere with comprehension.	5 pts

Total Points: 100

NURS_6512_Module2_AssignmentTemplate.docx

NURS 6512

Week 4 Assignment Template

Comprehensive Health History and Physical Examination Template

Part I: Comprehensive Health History (Subjective Data Only)

Subjective Data

Chief Complaint (CC):

History of Present Illness (HPI):

Past Medical History (PMH):

Surgical History (PSH):

Medications:

Allergies:

Preventive Health:

Social History:

Review of Systems (ROS) (Subjective Data Only – Patient-Reported Symptoms):

General:

Skin:

HEENT:

Cardiac:

Respiratory:

Gastrointestinal (GI):

Genitourinary (GU):

Musculoskeletal (MSK):

Neurologic:

Psychiatric:

Endocrine:

Hematologic/Lymphatic/Immune:

Part II: Focused Physical Examination (Objective Data Only)

Physical Examination (Objective Data Only – Do NOT include subjective statements):

General:

Skin:

Head:

Eyes:

Ears:

Nose:

Mouth/Throat:

Neck:

Cardiac:

Lungs:

Abdomen:

Genitourinary (GU):

Musculoskeletal:

Lower Extremities:

Neurologic:

Part III: Reflection

Part III, Section 1: Subjective vs. Objective Distinction

1. Identify two examples where it may have been challenging to separate subjective from objective data.

2. Explain how you ensured that patient-reported symptoms remained in the history section.

3. Explain how you ensured that only observable or measurable findings were included in the physical exam section.

Part III, Section 2: Additional Assessment Questions

Identify 2–3 additional questions you would ask to strengthen your subjective assessment.

For each question: • State the question • Briefly explain why it is important • Describe how the response could guide your focused physical examination

Part III, Section 3: Professional Growth

References

List 3–5 peer-reviewed references, less than 5 Years Old. Cite all sources in APA format.

NURS_6512_ComprehensiveHealthHistory_ReferenceSheet.pdf

NURS 6512: Comprehensive Health History Reference Sheet

Chief Complaint (CC)

History of Present Illness (HPI) – OLDCARTS + Pertinent History

Past Medical History (PMH)

• Chronic illnesses (HTN, DM, asthma, etc.) • Childhood illnesses (if relevant) • Hospitalizations and psychiatric history

Surgical History (PSH)

• List all surgeries/procedures with year, indication, and complications

Medications

• List all: prescription, OTC, herbal, and supplements • Include name, dose, route, frequency, indication • Note adherence and side effects

Allergies

• Drug, food, environmental — include reaction type (rash, anaphylaxis, etc.) • Document tolerated alternatives if known

Preventive Health

Social History

Review of Systems (ROS)

These are subjective symptoms that the patient reports. No objective exam findings should be included here.

InstrucWk4Assgnmt.docx

The Assignment

Based on the case, complete document a comprehensive health history (subjective data only) and a focused physical examination (objective data only).

Do NOT provide:

· A diagnosis

· A differential diagnosis list

· A treatment plan

· Prescriptions

· Patient education

This assignment evaluates assessment and documentation skills only.

Part I: Comprehensive Health History (Subjective Data Only)

Reminder: The health history includes only information provided by the patient. It should not include physical exam findings.

You must:

· Expand the HPI using OLDCARTS

· Write the HPI as a cohesive paragraph (not bullet points)

· Include complete PMH, PSH, medications, allergies, preventive health, social history, and SDOH

· Complete a comprehensive or focused ROS (subjective only)

Reminder: The physical exam includes only what the clinician observes, palpates, percusses, or auscultates.

You must:

· Perform and document a focused examination appropriate to the chief complaint,

· Determine and document what objective findings you would expect to assess and record based on your clinical reasoning.

Documentation Expectations

You must:

· Clearly separate subjective and objective data

· Avoid including patient-reported symptoms in the physical exam section

· Avoid including exam findings in the history section

· Use professional medical terminology

· Demonstrate logical organization

· Align examination scope with the chief complaint

Evidence-Based Practice Requirement

Your documentation must incorporate a minimum of three, evidence-based scholarly references published within the last five years (≤ 5 years old). Cite all sources in APA format.

References must support:

· Clinical assessment of integumentary complaints

· Focused skin examination principles

· Any portion of the reflection section

Acceptable Sources:

· Peer-reviewed journal articles

· CDC clinical guidance

· IDSA guidelines

· Advanced practice nursing scholarly texts

· WHO clinical documents

Unacceptable Sources:

· Patient education websites (e.g., Mayo Clinic, Cleveland Clinic, WebMD, Healthline)

· Wikipedia

· Blogs or commercial health sites

All references must be cited in APA format.

NURS_6512_Module2_Assignment_Rubric
Criteria	Ratings	Pts
This criterion is linked to a Learning OutcomePart I: Comprehensive Health History (Subjective Data Only)... Demonstrates accurate and complete documentation of patient comprehensive health history (subjective data only).	25 to >22.35 ptsExcellentProvides accurate and complete documentation of patient comprehensive health history (subjective data only). 22.35 to >19.85 ptsGoodProvides a mostly accurate and complete patient comprehensive health history (subjective data only); may contain some minor errors. 19.85 to >0 ptsPoorDoes not provide documentation of patient health history (subjective data only); documentation is inaccurate and/or incomplete.	25 pts
This criterion is linked to a Learning OutcomePart II: Focused Physical Examination (Objective Data Only)... Demonstrates accurate and complete documentation of patient focused physical examination (objective data only).	25 to >22.35 ptsExcellentProvides accurate and complete documentation of patient focused physical examination (objective data only). 22.35 to >19.85 ptsGoodProvides a complete, mostly accurate documentation of patient focused physical examination (objective data only); may contain some minor errors. 19.85 to >0 ptsPoorDoes not provide documentation of patient focused physical examination (objective data only); data provided is inaccurate and/or incomplete.	25 pts
This criterion is linked to a Learning OutcomePart III: Reflection Section 1: Subjective vs. Objective Distinction...Identify two examples where it may have been challenging to separate subjective from objective data; Explain how you ensured that patient-reported symptoms remained in the history section; Explain how you ensured that only observable or measurable findings were included in the physical exam section.	15 to >13.41 ptsExcellentProvides two fully developed examples of situations that posed a challenge separating subjective and objective data... Fully explains how they ensured that patient-reported symptoms remained in the history section... Fully explains how they ensured that only observable or measurable findings were included in the physical exam section. 13.41 to >11.91 ptsGoodProvides two adequately developed examples of situations that posed a challenge separating subjective and objective data... Adequately explains how they ensured that patient-reported symptoms remained in the history section... Adequately explains how they ensured that only observable or measurable findings were included in the physical exam section. 11.91 to >0 ptsPoorDoes not provide examples of situations that posed a challenge separating subjective and objective data; explanations are unclear or incomplete.	15 pts
This criterion is linked to a Learning OutcomePart III: Reflection Section 2: Additional Assessment Questions... Identify 2–3 additional questions you would ask to strengthen your subjective assessment.... For each question: State the question; Briefly explain why it is important; Describe how the response could guide your focused physical examination	10 to >8.94 ptsExcellentIdentifies 2–3 additional questions they would ask to strengthen their subjective assessment... Provides a fully developed explanation of why the question is important... Provides a fully developed description of how the response could guide their focused examination. 8.94 to >7.94 ptsGoodIdentifies 2–3 additional questions they would ask to strengthen their subjective assessment... Provides an adequately developed explanation of why the question is important... Provides an adequately developed description of how the response could guide their focused examination. 7.94 to >0 ptsPoorDoes not identify 2–3 additional questions they would ask to strengthen their subjective assessment; the questions provided are unclear, inaccurate, or incomplete.	10 pts
This criterion is linked to a Learning OutcomePart III: Reflection... Section 3: Professional Growth... Identify one area of your assessment skills that you would like to improve (e.g., documenting vesicular lesions, describing rash morphology, lymph node assessment). Briefly explain how you plan to strengthen that skill.	10 to >8.94 ptsExcellentIdentifies one area of their assessment skills they would like to improve... Provides a fully developed explanations of how they plan to strengthen that skill. 8.94 to >7.94 ptsGoodIdentifies one area of their assessment skills they would like to improve... Provides an adequately developed explanations of how they plan to strengthen that skill. 7.94 to >0 ptsPoorDoes not identify one area of assessment skills they would like to improve; explanation is unclear, inaccurate, or incomplete.	10 pts
This criterion is linked to a Learning OutcomeUses at least 3 scholarly resources that are less than 5 years old.	5 to >4.46 ptsExcellentUses 3 peer-reviewed scholarly sources published within the last 5 years. 4.46 to >3.96 ptsGoodUses 2 peer-reviewed scholarly sources published within the last 5 years. 3.96 to >3.46 ptsFairUses 1 peer-reviewed scholarly source published within the last 5 years. 3.46 to >0 ptsPoorDoes not use peer-reviewed scholarly sources or sources used are older than 5 years.	5 pts
This criterion is linked to a Learning OutcomeSource Attribution and APA Formatting	5 to >4.46 ptsExcellentAll sources are cited in APA format without any errors. 4.46 to >3.96 ptsGoodAll sources are cited in APA format with some minor errors. 3.96 to >3.46 ptsFairAll sources are cited with frequent APA formatting errors. 3.46 to >0 ptsPoorMissing source citations and/or minimal adherence to APA formatting rules.	5 pts
This criterion is linked to a Learning OutcomeGrammar, Mechanics, and Punctuation	5 to >4.46 ptsExcellentCorrect grammar, spelling, and punctuation with no errors. 4.46 to >3.96 ptsGoodCorrect grammar, spelling, and punctuation with few errors. 3.96 to >3.46 ptsFairCorrect grammar, spelling, and punctuation with frequent errors. 3.46 to >0 ptsPoorFrequent errors in grammar, spelling, and punctuation that interfere with comprehension.	5 pts

Total Points: 100

other Questions(10)

nursing

NURS_6512_Module2_AssignmentTemplate.docx

NURS_6512_ComprehensiveHealthHistory_ReferenceSheet.pdf

InstrucWk4Assgnmt.docx

NURS_6512_Module2_AssignmentTemplate.docx

NURS_6512_ComprehensiveHealthHistory_ReferenceSheet.pdf

InstrucWk4Assgnmt.docx

NURS_6512_Module2_AssignmentTemplate.docx

Nursing WEEK 4 ASSIGNMENT