shadow health documentation example

Assessment Liberty University Nursing tasks and Documentation, while they provide valuable practice for their real-world counterparts, are not automatically evaluated by the simulation. She denies coffee intake, but does drink diet cola on a regular basis. Objective Essential Environment: The Science Behind the Stories Jay H. Withgott, Matthew Laposata. Was this article helpful? 12/10/2018 Gastrointestinal Physical Assessment Assignment | Completed | Shadow Health 1/4 Gastrointestinal Physical Assessment Assignment Results | Turned In Advanced Health Assessment - Chamberlain, NR509-October-2018 Return to Assignment Your Results Lab Pass Lab Pass Document: Provider Notes Document: Provider Notes Student Documentation Student Documentation Model Documentation … Determine allergies, presence and dates of childhood and adult illnesses, chronic health problems, immunization history, and past hospitalizations Family History Determine age and health, or age and cause of death, of parents, sibling, and grandparents, noting the presence of specific illnesses in family (e.g. She notes it to increase with consumption of food and specifically fast food and spicy food make pain worse. Students must register to attend the debriefing session. How do I test my network connection? Debriefing Faculty will lead virtual debriefing sessions during Weeks 1-6. With a weak or incorrect assessment, nurses can create an incorrect nursing diagnosis and plans therefore creating wrong interventions and evaluation. , es is a pleasant 28-year-old African American woman who presented to the clinic with complaints of upper stomach pain after eating. Assessment can be called the “base or foundation” of the nursing process. Liver is 7 cm at the MCL and 1 cm below the right costal margin. NB: We have all the questions and documented answers in the SUBJECTIVE DATA, OBJECTIVE DATA, ASSESSMENT AND CARE PLAN format. This video demonstrates portions of two of these modules, patient history and HEENT, as well as a student's view of the Shadow Health Learning Management System and post-action reflection and review. She noticed the pain about a month ago. She denies known history of murmurs, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, or edema. You can click on the type of interaction to filter out that kind of interaction. How do I save my work? Biology Mary Ann Clark, Jung Choi, Matthew Douglas. Everything's an Argument with 2016 MLA Update University Andrea A Lunsford, University John J Ruszkiewicz. Devry University Denies nausea, vomiting, diarrhea, and constipation. For example, filtering by Statements will show you the statement from the patient that triggered your empathetic or educational response. Spleen and bilateral kidneys are not palpable. No tenderness to light or deep palpation. Popular books. No femoral, iliac, or renal bruits. (Health History) Pre-brief: Obtaining an accurate history is the critical first step in determining the etiology of a patient’s problem.A large percentage of the time, you will actually be able to make a diagnosis based on the history alone. Respiratory: Lung sounds clear to anteriourly and posteriorly presents all areas. Return to top Related articles. No known jaundice, problems with liver or spleen. • Gastrointestinal: States that in general her appetite is unchanged, although she does note that she will occasionally experience loss of appetite in anticipation of the pain associated with eating. • Abdominal: Abdomen is soft and protuberant without scars or skin lesions; skin is warm and dry, without tenting. She drinks alcohol occasionally, last was 2 weeks ago, and was 1 drink. Nursing assessment is an important step of the whole nursing process. Through the Shadow Health DCE, students engage with Digital Standardized Patients™ to perform patient exams, practice documentation and develop clinical reasoning skills. Focused Exam PTSD Completed Shadow Health documentation No adventitious sound noted. Student Response Model Documentation Identifying Data & Reliability A 28y/o African American female with bright affect ; pt weighs 90kg, BP 142/82, temp 101.1, Blood sugar 238mg/dl. Notes were already simplified made studying that much easier. This requires that your machines have av… You even benefit from summaries made a couple of years ago. Shadow Health: Anti-Asthmatic Concept Lab. How do I change my section? South University Social History: She denies any specific changes in her diet recently, but notes that she has increased her water intake. Ms Tina Jones is a 28 yo African Woman. Denies any change in stool color, consistency, or frequency. • Respiratory: She denies shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. The spleen and bilateral kidneys are not palpable. Test dates/times: March 19, 8am – March 20, 9pm Week 11 Comprehensive Adult History and Physical (Sample Summative H&P by M2 Student) Chief Complaint: “I got lightheadedness and felt too weak to walk” Source and Setting: Patient reported in an in-patient setting on Day 2 of his hospitalization. Focused Exam PTSD Completed Shadow Health documentation $7.45 Add to Cart Browse Study Resource | Subjects Accounting Anthropology Architecture Art Astronomy Biology Business Chemistry Communications Computer Science Tympanic sounds throughout abdomen, and spleen area. One of the most useful resource available is 24/7 access to study guides and notes. She maintains eye contact throughout interview and examination. No CVA tenderness noted. This evidence-based virtual reality simulation experience allows students to interview and examine digital standardized patients. DATA BASE: SAMPLE HISTORY IDENTIFYING DATA (Use patient’s initials, not full name) CM is a 45-year-old, widowed, white saleswoman, born in the U.S. CHIEF COMPLAINT “Bad headaches” HISTORY OF PRESENT ILLNESS (HPI, Problem by problem) For about 3 months Mrs. M. has been increasingly troubled by headaches that are right- Docmerit is super useful, because you study and make money at the same time! 5/26/2020 HEENT | Completed | Shadow Health 1/2 HEENT Results | Turned In Health Assessment - August 2017, NUR3067C Return to Assignment (/assignments/140510/) Documentation / Electronic Health Record Document: Provider Notes Student Documentation Model Documentation Subjective HPI. I find Docmerit to be authentic, easy to use and a community with quality notes and study tips. Ms. Jones is a pleasant, alert and oriented 28-year-old African American woman. The total score determines the clients “Assistance Level” and also determines how much the company will be reimbursed for the care of that client. College Physics Raymond A. Serway, Chris Vuille. Gastroesophageal reflux disease Differential diagnosis as cardiac disease, pregnancy, cholelithasis, pancreatitis, peptic ulcer disease, esophageal spasm, pulmonary edema. Pt has a wound on the right foot measuring 2cmx1.5cmx2.5mm. She does not exercise. Therefore, a cardiovascular exam should be a part of every abbreviated and complete assessment. Breakfast is usually a muffin or pumpkin bread, lunch is a sandwich with chips, dinner is a homemade meal of a meat and vegetable, snacks are French fries or pretzels. Mike T, Focused Exam PTSD Completed Shadow Health documentation. All you need to do is ORDER NOW for an equivalent of 4 pages and score 100% in this assignment and all other Shadow Health Assignments. The Advanced Health Assessment patient case is a series of single-system examinations of Tina Jones during several clinic visits over the course of a simulated year, which students have found useful in preparing for their clinical. Learn Digital Clinical Experience Shadow Health with free interactive flashcards. He denies drug use and does drink … She denies use of tobacco and illicit drugs. It helped me a lot to clear my final semester exams. SAMPLE Shadow Health Respiratory Assessment Model Documentation Subjective HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of shortness of breath and wheezing following a near asthma attack that she had two days ago. When is my assignment due? Now is my chance to help others. $7.45 Student Documentation Model Documentation History of Present Illness Ms. Jones denies any health concern, her visit for a physical exam for the health insurance at her new job. No tenderness to light or deep palpation. Shadow Health Partners Working together at the forefront of nursing and educational simulation. NR 509 Week 2 Assignment: You will need to complete either a debriefing session or the alternate writing assignment! She has a history of asthma, last hospitalization was age 16, last chest XR was age 16. cardiovascular health such as high blood cholesterol, cigarette use, diabetes, or hypertension (CDC, 2011). With a profile at Docmerit you are definitely prepared well for your exams. During the […] College Physics Raymond A. Serway, Chris Vuille. Denies blood in stool, dark stools, or maroon stools. We share your Personal Data with trusted third parties including, your academic institution and our third-party service providers. No bruits with auscultation over abdominal aorta. Review of Systems: General: Denies changes in weight and general fatigue. Anna Maria. David Smith. Everything's an Argument with 2016 MLA Update University Andrea A Lunsford, University John J Ruszkiewicz. The experience consists of 9 modules aligned with major topics in these courses, e.g. Shadow Health's extensive suite of healthcare simulation products for nursing and allied health care fields provide an effective, affordable, and scalable path to experiential and patient-centered learning. Grace. The virtual health assessments help students build critical skills and abilities necessary for physical assessments. Liver palpable. A focused cardiovascular assessment is usually indicated after a comprehensive assessment indicates a She describes it “kind of like heartburn” but states that it can be sharper. 2/6/2021 Focused Exam: Schizophrenia | Completed | Shadow Health 2/3 Student Documentation Model Documentation Social History Eric had girlfriend for some time now "going strong" He works at a local grocery strore 20-30 hours per week He is trying to get a degree in a Audio Visual but due to the voices he reports he has been unable to go for a week. No blood in emesis. She does notice that she has increased burping after meals. Pain is a 5/10 and is located in her upper stomach. Lung sounds clear to auscultation anteriorly and posteriorly without wheezes, crackles, or cough. Sample SBAR Shadow Health- End of Life Documentation Review/Sample SBAR Shadow Health- End of Life Documentation Review/Sample SBAR Shadow Health- End of Life Documentation Review Bowel movements are daily and generally brown in color. history taking, HEENT, cardiovascular, mental health, etc. Bowel sounds present and normoactive in all quadrants. • Respiratory: Chest is symmetrical with respirations. Bowel sounds present and normaoactive in all quadrants. All Providers must use BHRS approved forms or an approved electronic health record system for documentation. Her last clinical visit was about five months ago, she got metformin and gynecologist for a pap smear a few weeks later. Cardiovascular: S1, S2 present. Biology Mary Ann Clark, Jung Choi, Matthew Douglas. Care Plan; Experience Overview Page While in the exam room with a patient, you will have access to the Electronic Health Record, or EHR. Documentation is a major part of any medical work, and it’s no different in Shadow Health. Shadow Health Gastrointestinal Documentation Documentation / Electronic Health Record • Document: Provider Notes Document: Provider Notes Student Documentation Model Documentation HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of upper stomach pain after eating. Shadow Health does not sell or rent Personal Data to marketers or unaffiliated third parties. Docmerit provided me with a simpler way to understand difficult topics. The value of the history, of course, … Gastroesophageal reflux disease without evidence of esophagitis No CVA tenderness. Essential Environment: The Science Behind the Stories Jay H. Withgott, Matthew Laposata. Each assignment will have different sections within the EHR for you to view and use. The Shadow Health system is an exciting, important, and required component of this course. How to get a refund for your Shadow Health product license; How do I perform physical assessments? Shadow Health Online Case 03: Focused Exam: Community-Acquired Pneumonia (Anita Douglas) Weekly Assignment: Quiz 5 Due March 13, by 11:59pm Unit 15 Week 10. 3. No bruits over abdominal aorta, femoral, iliac, or renal with auscultation. The date, time, and duration of the weekly debriefing session will be posted by the course faculty. She noticed the pain about a month ago. General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. Shadow Health’s patient cases are designed for both novice and expert students to practice communicating with and examining patients. March 16-21 Exam #2: Due March 20, by 11:59pm, Week 6-9. Where do I document my findings? Add to Cart. Popular books. At the top of the transcript, you'll see a ribbon indicating the frequency of each kind of interaction within the transcript. The more thorough your documentation, the easier it Gastrointestinal: symmetric, protuberant, no visible abnormalities noted. • Cardiac: Denies a diagnosis of hypertension, but states that she has been told her blood pressure was high in the past. For example: The documentation you provide is reviewed and scored (as above) and sent to Medicare/Medicaid for reimbursement. • Cardiovascular: Regular rate and rhythm, S1 and S2 present, no murmurs, rubs, gallops, clicks, precordial movements. She states that she experiences pain daily, but notes it to be worse 3-4 times per week. Clinician’s Gateway, the hybrid health record continues to include chart forms that require client’s signature until signature pads and/or scanning capabilities become available system wide. ... A Model Statement is provided as an example … She is alert and oriented. Esther park abdominal pain shadow health, , Transcript. Choose from 100 different sets of Digital Clinical Experience Shadow Health flashcards on Quizlet. Shadow Health Respiratory Assessment Pre Brief. How do I add a new course to my account? ……………………………………..CONTINUED…………………………. She states that time generally makes the pain better, but notes that she does treat the pain “every few days” with an over the counter antacid with some relief. Tympanic throughout. She denies fevers, chills, and night sweats. University Of Arizona Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation(Found)Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.Example Question:Can I confirm that you are here for a physical?

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