Nursing WEEK 4 ASSIGNMENT

This week you will continue building the assessment and documentation skills that are essential for advanced practice nursing. Your focus this week is  Simulation Case Study #2: Painful Rash, where you will demonstrate your ability to collect, organize, and document both subjective and objective patient data.

Remember—the goal of this assignment is not to diagnose or treat the patient. Instead, think like a clinician gathering information and documenting findings that will support future clinical decision-making.

📋 Assignment Overview

This assignment is divided into three parts:

Part I: Comprehensive Health History (Subjective Data Only)

The health history includes only information reported by the patient.

Be sure to:

· Expand the HPI using  OLDCARTS

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

· Include complete:

· Past Medical History (PMH)

· Past Surgical History (PSH)

· Medications

· Allergies

· Family History

· Preventive Health

· Social History

· Social Determinants of Health (SDOH)

· Complete a focused Review of Systems (ROS)

💡  Tip: If specific information is not provided in the case study, you may create reasonable subjective findings and history details to complete the assessment. The goal is complete and professional documentation.

Part II: Focused Physical Examination (Objective Data Only)

The physical examination includes only what the clinician observes, palpates, percusses, or auscultates.

Be sure to:

· Perform and document a focused exam appropriate to the chief complaint

· Document expected objective findings based on your clinical reasoning

· Use professional medical terminology

· Maintain logical organization

· Align the examination with the patient's presenting complaint

🚫 Do NOT Include

This assignment evaluates assessment and documentation skills only.

Do not include:

· Diagnosis

· Differential diagnoses

· Treatment plan

· Prescriptions

· Patient education

🔍 Documentation Tips

One of the biggest opportunities for success on this assignment is clearly separating  subjective and  objective findings.

Subjective = What the Patient Reports

Examples include:

· Symptoms

· Health history

· Symptoms the patient admits or denies during the ROS

· Patient concerns

Objective = What the Clinician Finds

Examples include:

· Inspection findings

· Palpation findings

· Percussion findings

· Auscultation findings

A helpful question to ask yourself:

"Did the patient tell me this, or did I observe it?"

If the patient reported it, it belongs in the history. If you observed it, it belongs in the physical exam.

📚 Evidence-Based Practice Requirement

You must include a minimum of  three scholarly references published within the last five years.

References should support:

· Clinical assessment of integumentary complaints

· Focused skin examination principles

· Reflection content

Acceptable sources include:

· Peer-reviewed journal articles

· CDC clinical guidance

· IDSA guidelines

· Advanced practice nursing scholarly texts

· WHO clinical documents

Please ensure all references and citations are formatted according to  APA guidelines.

✍️ Part III: Reflection

After completing your documentation, complete the reflection section included in the assignment template.

This is your opportunity to reflect on:

· Separating subjective and objective findings

· Integumentary assessment skills

· Clinical reasoning and documentation development

✅ Before You Submit

Be sure to review:

· Learning Resources from Weeks 1–4

· Comprehensive Health History Reference Sheet

· Physical Exam Reference Sheet

· Simulation Case Study #2: Painful Rash

· Current evidence-based guidelines related to the patient's complaint

· Assignment Template

· Assignment Rubric

The rubric is your roadmap to success—use it as a checklist before submitting your work.

REQUIRED SOURCES:

NOTE: Utilize this text as a clinical reference to aid your analysis for the relevant areas noted.  Also utilize study questions to develop your understanding of the concepts and topics presented throughout this course.

· Soriano, R. P. (2026).  Bates’ guide to physical examination and history taking(14th ed.). Wolters Kluwer Health. 

· Chapter 13, "Head and Neck" 

· Chapter 14, "Eyes" 

· Chapter 15, "Ears and Nose" 

· Chapter 16, "Throat and Oral Cavity" 

· American College of Radiology. (n.d.).  Appropriateness Criteria Links to an external site. . https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria 

· Document:  Comprehensive Health History Reference Sheet (PDF) Download Comprehensive Health History Reference Sheet (PDF)

· Document:  Physical Exam Reference Sheet (PDF) Download Physical Exam Reference Sheet (PDF)

· Document:  Week 4 Assignment Template (Word) Download Week 4 Assignment Template (Word)

· Walden University, LLC. (n.d.).  Simulation case study #2: Painful rashLinks to an external site. . Walden University Canvas. https://waldenu.instructure.com

INSTRUCTIONS:

· Review Learning Resources in Weeks 1–4. 

· Download and review the “ Comprehensive Health History Reference Sheet Download Comprehensive Health History Reference Sheet” and the “ Physical Exam Reference Sheet Download Physical Exam Reference Sheet.” 

· Access  Simulation Case Study #2: Painful RashLinks to an external site. .  

· Review current evidence-based guidelines related to the patient complaint. 

· Download the Assignment Template Download Download the Assignment Template.

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) 

Part II: Focused Physical Examination (Objective Data 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. 

Part III: Reflection (1–2 pages)

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. 

RUBRIC:

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