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Shadow Health Tina Jones Cardiovascular ALL Subjective Objective Education Documentation

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Shadow Health Tina Jones Cardiovascular ALL Subjective Objective Education Documentation

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2/15/2021 Cardiovascular | Completed | Shadow Health
shadow
Cardiovascular Results | Turned In
Nursing 562/562L Advanced Health Assessment - Spring 2021, N562
Return to Assignment (/assignments/433794/)




Your Results Reopen (/assignment_attempts/9117273/reopen)

Lab Pass (/assignment_attempts/9117273/lab_pass.pd




Overview
Experience Overview
Transcript

Subjective Data Collection
Patient: Tina Jones Student Performance Index
Objective Data Collection 47 out of 47
Education & Empathy

Documentation




Proficiency Level: Proficient
Beginning Developing Proficient

Students rated as “proficient” demonstrate an entry-level expertis
advanced practice competencies and clinical reasoning skills
Digital Clinical Experience Score comparable programs, the top 25% of students perform at the l
of a proficient practitioner.




100%
Subjective Data Collection Objective Data Collection
19 out of 19 23 out of 23

Education and Empathy
This score measures your performance on the Student Performance 5 out of 5
Index in relation to other students in comparable academic programs.
Your instructor has chosen to scale your Student Performance Index Time
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
96 minutes total spent in assignment
additional components, such as documentation or time spent.
Interaction with patient
96 minutes



Comments

If your instructor provides individual feedback on this assignment, it will appear here.




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https://app.shadowhealth.com/assignment_attempts/9117273 1/1

,2/15/2021 Cardiovascular | Completed | Shadow Health


Cardiovascular Results | Turned In
Nursing 562/562L Advanced Health Assessment - Spring 2021, N562
Return to Assignment (/assignments/433794/)




Your Results Reopen (/assignment_attempts/9117273/reopen)

Lab Pass (/assignment_attempts/9117273/lab_pass.pd




Overview
Subjective Data Collection: 19 of 19 (100.0%)
Transcript

Subjective Data Collection
Hover To Reveal... Indicates an item that you
Objective Data Collection found.
Hover over the Patient Data items Indicates an item that is
Education & Empathy below to reveal important available to be found.
information, including Pro Tips and
Documentation
Example Questions.




Category Scored Items Patient Data
Not Scored

Experts selected these topics as essential components A combination of open and closed questions will yield
of a strong, thorough interview with this patient. better patient data. The following details are facts of t
patient's case.



Chief Complaint


Established chief complaint Reports recent episodes of palpitations
Describes heart rate during episodes as feeling
"faster than usual"



History of Presenting Illness


Asked about onset Reports first episode a month ago



Asked about frequency and duration of fast Reports episodes occur "about once a week"
heartbeat episodes 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


https://app.shadowhealth.com/assignment_attempts/9117273 1/3

, 2/15/2021 Cardiovascular | Completed | Shadow Health
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



Medical History


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 Reports no known history of heart disease
health history 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



Social Determinants of Health


Asked about stress and anxiety Reports occasional feelings of anxiety
Reports recent increase in stress
Reports stress related to school and work



Social History


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 level

https://app.shadowhealth.com/assignment_attempts/9117273 2/3

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