- Review this week’s Learning Resources, and download and review the Physical Examination Objective Data Checklist as well as the Student Checklists and Key Points documents related to neurologic system and mental status.
- Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation with the Shadow Health platform. Review the examples also provided.
- Review the DCE (Shadow Health) Documentation Template for Comprehensive (Head-to-Toe) Physical Assessment found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
- Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
- Review the Week 9 DCE Comprehensive Physical Assessment Rubric provided in the Assignment submission area for details on completing the Assessment in Shadow Health.
- Also, your Week 9 Assignment 3 should be in the Complete SOAP Note format. Refer to Chapter 2 of the Sullivan text and the Week 4 Complete Physical Exam template and use the template below for your submission.
Week 9 Shadow Health Comprehensive SOAP Note Documentation Template Download Week 9 Shadow Health Comprehensive SOAP Note Documentation Template
Note: There are 2 parts to this assignment – the lab pass and the documentation. You must achieve a total score of 80% in order to pass this assignment. Carefully review the rubric and video presentation in order to fully understand the requirements of this assignment.
DCE COMPREHENSIVE PHYSICAL ASSESSMENT:
Complete the following in Shadow Health:
- Episodic/Focused Note for Comprehensive Physical Assessment of Tina Jones (180 minutes)
ANSWER
Comprehensive SOAP Note for Tina Jones
Patient Information:
TJ, 28 years old, African American female
S.
CC: “I’m required to have a recent physical exam for the health insurance at my new job.”
HPI:
Ms. TJ, a 28-year-old female patient reports to the clinic for a comprehensive physical exam for her upcoming job as an accountant. She had two previous appointments earlier in the year. ……please click the icon below to access entire answer at $15