Danny Rivera
Pediatric Cough Shadow Health Assessment SBAR, Subjective data Collection
Objective Data Collection Documentation and Care Plan
Experience Overview
Patient: Danny Rivera
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 80.0%. 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
19 out of 19
Proficiency Level: Beginning
Students rated as “beginning” are starting to develop their nursing competencies
and clinical reasoning skills. In comparable nursing programs, 50% of students
perform at the level of a beginning nurse. Review your results in the tabs on the left
side of the page to identify areas for improvement.
Your Results 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 the patient's case.
Chief Complaint
• Finding:
Established chief complaint
• Finding:
Reports cough
(Found)
Pro Tip: Asking a patient broadly about their chief complaint allows them to
answer in their own words and confirm information that you may have
already received from another source.
Example Question:
Do you have a cough?
History of Presenting Illness
• Finding:
Asked about onset of cough
• Finding:
Reports cough started 3 days ago
(Found)
Pro Tip: Whenever you are assessing a symptom or a health condition, in this
case the patient's cough, inquiring about onset assesses the severity and the
progression of the problem.
Example Question:
How long have you had a cough?
,• Finding:
Asked about characteristics of cough
• Finding:
Reports cough is wet
(Found)
Pro Tip: The characteristics of a cough, such as whether it is dry or wet, can
indicate key information about the type of illness the patient has.
Example Question:
Is your cough a wet cough?
• Finding:
Reports clear sputum with cough
(Found)
Pro Tip: The characteristics of a cough, such as whether it is productive, can
indicate key information about the type of illness the patient has.
Example Question:
Do you produce any phlegm or sputum with your cough?
• Finding:
Asked about frequency and duration of cough
• Finding:
Reports coughing every few minutes
(Found)
Pro Tip: Establishing how frequently Danny coughs will illustrate how long
he has been suffering these particular symptoms and might indicate possible
triggers.
, Example Question:
How frequently are you coughing?
• Finding:
Reports coughs last a couple minutes
(Found)
Pro Tip: Establishing how long Danny's coughs last will illustrate how long he
has been suffering these particular symptoms and might indicate possible
triggers.
Example Question:
How long do your coughs last?
• Finding:
Asked about aggravating factors for cough
• Finding:
Reports cough is worse at night
(Found)
Pro Tip: Establishing a timeline for Danny's coughing will illustrate how long
he has been suffering these particular symptoms and might indicate possible
triggers.
Example Question:
Is the cough worse at night?
• Finding:
Denies smoking
(Available)
Pro Tip: Tobacco use puts the patient at risk for many medical conditions.
Asking even young patients about whether they consume tobacco products
helps you assess this risk factor.
Pediatric Cough Shadow Health Assessment SBAR, Subjective data Collection
Objective Data Collection Documentation and Care Plan
Experience Overview
Patient: Danny Rivera
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 80.0%. 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
19 out of 19
Proficiency Level: Beginning
Students rated as “beginning” are starting to develop their nursing competencies
and clinical reasoning skills. In comparable nursing programs, 50% of students
perform at the level of a beginning nurse. Review your results in the tabs on the left
side of the page to identify areas for improvement.
Your Results 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 the patient's case.
Chief Complaint
• Finding:
Established chief complaint
• Finding:
Reports cough
(Found)
Pro Tip: Asking a patient broadly about their chief complaint allows them to
answer in their own words and confirm information that you may have
already received from another source.
Example Question:
Do you have a cough?
History of Presenting Illness
• Finding:
Asked about onset of cough
• Finding:
Reports cough started 3 days ago
(Found)
Pro Tip: Whenever you are assessing a symptom or a health condition, in this
case the patient's cough, inquiring about onset assesses the severity and the
progression of the problem.
Example Question:
How long have you had a cough?
,• Finding:
Asked about characteristics of cough
• Finding:
Reports cough is wet
(Found)
Pro Tip: The characteristics of a cough, such as whether it is dry or wet, can
indicate key information about the type of illness the patient has.
Example Question:
Is your cough a wet cough?
• Finding:
Reports clear sputum with cough
(Found)
Pro Tip: The characteristics of a cough, such as whether it is productive, can
indicate key information about the type of illness the patient has.
Example Question:
Do you produce any phlegm or sputum with your cough?
• Finding:
Asked about frequency and duration of cough
• Finding:
Reports coughing every few minutes
(Found)
Pro Tip: Establishing how frequently Danny coughs will illustrate how long
he has been suffering these particular symptoms and might indicate possible
triggers.
, Example Question:
How frequently are you coughing?
• Finding:
Reports coughs last a couple minutes
(Found)
Pro Tip: Establishing how long Danny's coughs last will illustrate how long he
has been suffering these particular symptoms and might indicate possible
triggers.
Example Question:
How long do your coughs last?
• Finding:
Asked about aggravating factors for cough
• Finding:
Reports cough is worse at night
(Found)
Pro Tip: Establishing a timeline for Danny's coughing will illustrate how long
he has been suffering these particular symptoms and might indicate possible
triggers.
Example Question:
Is the cough worse at night?
• Finding:
Denies smoking
(Available)
Pro Tip: Tobacco use puts the patient at risk for many medical conditions.
Asking even young patients about whether they consume tobacco products
helps you assess this risk factor.
