Document: Provider Notes

Student Documentation	Model Documentation
Subjective is an 8 year old male patient who reports to have had a cough for the last 4 to 5 days. He reports the cough is worse at night and makes him not sleep well and also gets fatigued. He describes the cough as watery. He also has a running nose. He has mild soreness in his throat which he relieves with over the counter drugs. He had ear infections when young and had pneumonia in the past. He denies any headache, dizziness, fever, sputum, chest pain, , abdominal pain or breathing problems. His cough does not get worse when he is active.	Return to Canvas to complete your SOAP note for this assignment. Pediatric Cough Shadow Health for Danny Rivera
Objective HEET: Mucus membranes are moist, with a clear nasal discharge. Redness, cobblestoning at the back of the throat. Eyes are dull with pink conjuctiva. Right tympanic memebrane is inflamed . It is also red. The right cervical lymph node is tender and enlarged. Cardiovasicular: S1, S2. There is neither murmurs, gallops nor rubs. Respiratory: Respiratory rate is increased but no distress. Breath sounds are clear to auscultation and negative bronchophony. The chest wall is resonant to percusion. Spirom… Pediatric Cough Shadow Health for Danny Rivera

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Week 4: SBAR Focused Exam: Cough Results | Turned In – Pediatric Cough Shadow Health for Danny Rivera

NUR 3069C Health Assessment and Communication – May ’18 (Gannon – Jacksonville Only), 3069C

Return to Assignment

 

 

 

 

 

 

Your Results

Lab Pass

 

 

 

 

 

 

 

Overview

 

Transcript

 

Subjective Data Collection

 

Objective Data Collection

Experience Overview

 

Patient: Danny Rivera

 

 

 

Student Performance Index

32.95 out of 34

 

 

Documentation

 

SBAR

 

 

 

 

 

Proficiency Level: Proficient

 

 

 

 

Digital Clinical Experience Score – Pediatric Cough Shadow Health for Danny Rivera

 

96.9%

Beginning        Developing        Proficient

 

 

Students rated as “proficient” demonstrate entry-level expertise in nursing competencies and clinical reasoning skills. In comparable nursing programs, the top 25% of students perform at the level of a proficient nurse.

 

 

 

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

Subjective Data Collection

19 out of 19

 

 

Time

Objective Data Collection

13.95 out of 15

 

documentation or time spent.

72 minutes total spent in assignment

 

 

Interaction with patient

72 minutes

Objective Data Collection: 13.95 of 15 (93%) Pediatric Cough Shadow Health for Danny Rivera

 

 

 

Correct Partially correct

Incorrect Missed

 

 

 

 

Inspected eyes and orbital area                                1 of 1 point

 

 

Orbital Area (1/4 point)                                                        Sclera (1/4 point)

 

 

No visible abnormal findings Ptosis

Eyelid Lesion

White Yellow tint Redness

 

 

Conjunctiva (1/4 point)                          Conjunctival Discharge (1/4 point)

 

 

Moist and pink Dry appearance Redness Swelling

No discharge

Clear, watery discharge Purulent discharge

 

 

 

 

Inspected nasal cavities                            0.75 of 1 point

 

 

Color (No point)                                                                                              Discharge (1/4 point)

 

 

Pink Red Bluish

No discharge Clear discharge Bloody discharge Purulent discharge

 

 

Turbinate Patency (1/4 point)                                                                                  Observations (1/4 point)

 

 

Patent

Decreased patency Not patent

No additional visible abnormal findings Foreign body present

Polyp

Septum perforated Septum deviated Lesion

 

 

 

 

Inspected ears                              0.8 of 1 point

 

 

Right: Auditory Canal Color (No point)                                      Right: Tympanic Membrane Color (No point) Pediatric Cough Shadow Health for Danny Rivera

 

 

Pink Red Pallor

Pearly gray Red Opaque Yellow

Not visible because of cerumen

 

 

 

Right: Tympanic Membrane Appearance (1/10 point)

No visible abnormal findings Fluid observed

Visible scars Bulging

 Perforation

Retraction

Right: Cone Of Light (1/10 point)

 

5:00

Cone of light distorted

 

Right: Discharge (1/10 point)                                         Left: Auditory Canal Color (1/10 point)

 

No discharge Cerumen

Clear discharge Bloody discharge Purulent discharge

Pink Red Pallor

 

 

Left: Tympanic Membrane Color (1/10 point)                                         Left: Tympanic Membrane Appearance (1/10 point)

 

 

Pearly gray Red Opaque Yellow

Not visible because of cerumen

No visible abnormal findings Fluid observed

Visible scars Bulging Perforation Retraction

 

 

Left: Cone Of Light (1/10 point)                                         Left: Discharge (1/10 point)

 

 

7:00

Cone of light distorted

No discharge Cerumen

Clear discharge Bloody discharge Purulent discharge

 

 

 

 

Inspected mouth and throat                              0.4 of 1 point

 

 

Oral Mucosa (No point)                                                        Tonsils (No point) Pediatric Cough Shadow Health for Danny Rivera

 

 

Moist and pink Dry appearance Redness

No visible abnormal findings Swelling

Redness

 

 

Throat Color (1/5 point)                                     Throat Texture (1/5 point)

 

 

Pink Red

No abnormal findings Cobblestoning Exudate

 

 

Post Nasal Drip (No point)

 

No discharge Clear discharge Purulent discharge

 

 

 

Inspected neck                                1 of 1 point

 

 

Symmetry (1/2 point)                                                                                       Appearance (1/2 point)

 

 

Symmetric Asymmetric

No visible abnormal findings Swelling

Visible pulsation Visible mass Discoloration

 

 

Inspected chest                                1 of 1 point

 

Symmetry (1/2 point)                                                                                       Appearance (1/2 point)

 

 

Symmetric Asymmetric

No visible abnormal findings Rash

Barrel chest

Intercostal retraction while breathing Excessive use of accessory muscles while

breathing

Skin growths (freckles or moles)

 

 

 

 

Auscultated breath sounds                                1 of 1 point

 

 

Breath Sounds (1/3 point)                          Adventitious Sounds (1/3 point)

 

 

Present in all areas Diminished in some areas Absent in some areas

No adventitious sounds Wheezing

Fine crackles Stridor Rhonchi Rales

 

 

Location (1/3 point) Pediatric Cough Shadow Health for Danny Rivera

 

All areas clear

Adventitious sounds in anterior right upper lobe Adventitious sounds in anterior right middle lobe Adventitious sounds in anterior right lower lobe Adventitious sounds in anterior left upper lobe Adventitious sounds in anterior left lower lobe Adventitious sounds in posterior right upper lobe Adventitious sounds in posterior right lower lobe Adventitious sounds in posterior left upper lobe Adventitious sounds in posterior left lower lobe

 

 

 

Auscultated for bronchophony                                1 of 1 point

 

Bronchophony (1/1 point)

 

Positive Negative

 

 

 

Auscultated heart sounds                                1 of 1 point

 

 

Heart Sounds (1/2 point)                                        Extra Heart Sounds (1/2 point)

 

 

S1 and S2 audible

S1, S2, and S3 audible S1, S2, and S4 audible

S1, S2, S3, and S4 audible

No extra sounds Gallops

Murmur Friction rub Valve clicks

 

 

 

Percussed chest wall                                1 of 1 point

 

Observations (1/2 point)                                                      Location (1/2 point)

 

 

All areas resonant

Some areas dull, some resonant

Some areas hyperresonant, some resonant

No areas of dullness

Dullness, anterior right upper lobe Dullness, anterior right middle lobe Dullness, anterior right lower lobe Dullness, anterior left upper lobe Dullness, anterior left lower lobe Dullness, posterior right upper lobe Dullness, posterior right lower lobe Dullness, posterior left upper lobe Dullness, posterior left lower lobe

 

 

 

 

Measured diaphragmatic excursion                                1 of 1 point

 

Range (1/1 point) Pediatric Cough Shadow Health for Danny Rivera

 

3-5 cm

Greater than 3-5 cm Less than 3-5 cm

 

 

 

Palpated sinuses                                1 of 1 point

 

 

Frontal (1/2 point)                                                                 Maxillary (1/2 point)

 

 

None reported Tenderness reported

None reported Tenderness reported

 

 

 

 

Palpated lymph nodes                                1 of 1 point

 

 

Head And Neck (1/3 point)                     Supraclavicular (1/3 point)

 

 

No palpable nodes

Palpable nodes on right side Palpable nodes on left side

No palpable nodes

Palpable nodes on right side Palpable nodes on left side

 

 

Axillary (1/3 point)

 

No palpable nodes

Palpable nodes on right side Palpable nodes on left side

 

 

 

Palpated fremitus                                1 of 1 point

 

 

Symmetry (1/2 point)                                                            Vibration (1/2 point)

 

 

Equal bilaterally Unequal bilaterally

Expected fremitus Decreased fremitus

 

 

 

 alpated chest expansion                                                                               1 of 1 point

 

Symmetry (1/1 point) Pediatric Cough Shadow Health for Danny Rivera