Health History Results | Turned In Advanced Health Assessment – Chamberlain – April 2019, NR509-April-2019
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Your Results Lab Pass Lab Pass
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.
Patient: Tina Jones
Digital Clinical Experience Score
Beginning Developing Proficient
Subjective Data Collection 104 out of 104
Objective Data Collection 1 out of 1
Education and Empathy 3 out of 11
Information Processing 39 out of 40
Interaction with patient 128 minutes
Post-exam activities 145 minutes
Time 273 minutes total spent in assignment
Student Performance Index 147 out of 156
Proficiency Level: Proficient
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.
Document: Provider Notes
Subjective Data Collection
Objective Data Collection
Education & Empathy
Health History Tips and Tricks
Documentation / Electronic Health Record
Th is s
tud y r
e w as
Document: Provider Notes
Student DocumentationStudent Documentation Model DocumentationModel Documentation
Identifying Data & Reliability
Tina arrived today complaining about a wound on her right foot. The wound is 2cm x 1.5cm with a depth of 2.5mm. The patient is experiencing pain as a result of the fall and wound. She is taking advil for pain with minium effectiveness. Instructed patient to take medication every 6 to 8 hours as needed for pain. Patient also presented with a fever, a high blood glucose and elevate blood cover. Patient has a family history of high blood pressure. Culture taken of wound and sent to lab. Eduated patient on importance of maintaing a safe blood sugar.
Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents to establish care and with a recent right foot injury. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview.
Patient is in school and has been understress while in school. Patient not concentrating on health due to stress. Educated patient on the importance of stress relief. Patiet is not currntly in a relationshiop and lives with family. Pt has a history of asthma which is currently mild with albuterol use a couple of times a week.
Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene.
The patient’s chief complaint is an infected wound on the right foot due to a fall. This is a followup visit from the ER.
“I got this scrape on my foot a while ago, and I thought it would heal up on its own, but now it’s looking pretty nasty. And the pain is killing me!”
History Of Present Illness
Patient fell and visited the ER where the wound was cleaned and she was given pain medication. She is in pain currently and stated that she is unable to use it to move independently.
Ms. Jones reports that a week ago she tripped while walking on concrete stairs outside, twisting her right ankle and scraping the ball of her foot. She sought care in a local emergency department where she had x-rays that were negative; she was treated with tramadol for pain. She has been cleansing the site twice a day. She has been applying antibiotic ointment and a bandage. She reports that ankle swelling and pain have resolved but that the bottom of the foot is increasingly painful. The pain is described as “throbbing” and “sharp” with weight bearing. She states her ankle “ached” but is resolved. Pain is rated 7 out of 10 after a recent dose of tramadol. Pain is rated 9 with weight bearing. She reports that over the past two days the ball of the foot has become swollen and increasingly red; yesterday she noted discharge oozing from the wound. She denies any odor from the wound. Her shoes feel tight. She has been wearing slip-ons. She reports fever of 102 last night. She denies recent illness. Reports a 10-pound, unintentional weight loss over the month and increased appetite. Denies change in diet or level of activity.