Tina Jones Cardiovascular Shadow Health. ALL Subjective Objective Education Documentation | Already Graded A+

Document Content and Description Below

Cardiovascular | Completed | Shadow Health https://app.shadowhealth.com/assignment_attempts/9117273 1/1 Cardiovascular Results | Turned In Nursing 562/562L Advanced Health Assessment - Spring 2021,... N562 Return to Assignment (/assignments/433794/) Experience Overview Your Results Reopen (/assignment_attempts/9117273/reopen) Lab Pass (/assignment_attempts/9117273/lab_pass.pd Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Patient: Tina Jones Digital Clinical Experience Score 100% 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 86.0%. 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 47 out of 47 Proficiency Level: Proficient Students rated as “proficient” demonstrate an entry-level expertis advanced practice competencies and clinical reasoning skills comparable programs, the top 25% of students perform at the l of a proficient practitioner. Beginning Developing Proficient Subjective Data Collection 19 out of 19 Objective Data Collection 23 out of 23 Education and Empathy 5 out of 5 Time 96 minutes total spent in assignment Interaction with patient 96 minutes Comments If your instructor provides individual feedback on this assignment, it will appear here. Return to Assignment (/assignments/433794/) Subjective Data Collection: 19 of 19 (100.0%) Chief Complaint History of Presenting Illness Your Results Reopen (/assignment_attempts/9117273/reopen) Lab Pass (/assignment_attempts/9117273/lab_pass.pd Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Indicates an item that you found. 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 t patient's case. Established chief complaint Reports recent episodes of palpitations Describes heart rate during episodes as feeling "faster than usual" Asked about onset Reports first episode a month ago Asked about frequency and duration of fast heartbeat episodes Reports episodes occur "about once a week" Reports 3-4 episodes total Reports fast heartbeat episodes last 5-10 minutes Asked about character of palpitations Describes palpitations as "thumping" or "pounding" Reports episodes accompanied by mild anxiety Asked about aggravating factors Reports that palpitations seem to occur more often in the morning Reports episodes not exacerbated by exertion Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.2/15/2021 Cardiovascular | Completed | Shadow Health Medical History Social Determinants of Health Social History Reports that episodes do not occur after eating Reports caffeine as a possible aggravating factor Asked about relieving factors Reports deep breathing and trying to relax Denies medication or other treatment Confirmed use of medications Confirms medications from previous visit Reports new inhaler Followed up on new inhaler New inhaler is Flovent Prescribed dose is two puffs Inhaler is prescribed for daily use Describes new inhaler regiment as effective Confirmed allergies Confirms allergies (no new allergies reported) Asked about personal history of hypertension Reports usual blood pressure "might be on the high side" Denies past diagnosis of hypertension Does not check BP regularly Is aware of risk factors for hypertension Asked about possible contributing factors in health history Reports no known history of heart disease Reports type 2 diabetes Reports no past diagnosis of high cholesterol Reports no history of rheumatic fever Reports no history of heart murmur Reports no EKG or other diagnostic cardiac tests Asked about stress and anxiety Reports occasional feelings of anxiety Reports recent increase in stress Reports stress related to school and work Asked about typical diet Breakfast is usually a muffin or pumpkin bread Lunch is usually a sandwich Dinner is usually a home-cooked meat dish and side of vegetables Snacks are pretzels or French fries Asked about caffeine consumption Reports increased caffeine consumption Reports consuming diet soda or energy drinks Reports caffeine increase was over last month Typical drinks 2 energy drinks before class Reports caffeine "keeps me focused but sometimes makes me jittery" Asked about exercise and activity level Reports general low activity level2/15/2021 Cardiovascular | Completed | Shadow Health Review of Systems Family History Asked about substance use Reports occasional consumption of alcohol Last alcoholic drink was two weeks ago Denies history of tobacco use, including cigarettes Denies drug use Asked about general symptoms Denies recent respiratory or other illness Denies fever Denies nausea or vomitting Denies chills Reports low energy level Denies night sweats Asked about review of systems for cardiovascular Denies shortness of breat [Show More]

Last updated: 1 week ago

Preview 4 out of 18 pages