Assignment 2: Digital Clinical Experience: Focused Exam: Cough NURS 6512N-32

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Assignment 2: Digital Clinical Experience: Focused Exam: Cough NURS 6512N-32

Assignment 2: Digital Clinical Experience: Focused Exam: Cough NURS 6512N-32

In this DCE Assignment, you will conduct a focused exam related to cough in your DCE using the simulation tool, Shadow Health. You will determine what history should be collected from the patient, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.

Photo Credit: Getty Images

To Prepare

  • Review this week’s Learning Resources and consider the insights they provide related to ears, nose, and throat.
  • Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation within the Shadow Health platform. Review the examples also provided.
  • Review the DCE (Shadow Health) Documentation Template for Focused Exam: Cough found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
    Assignment 2 Digital Clinical Experience Focused Exam Cough NURS 6512N-32.PNG

    Assignment 2 Digital Clinical Experience Focused Exam Cough NURS 6512N-32.PNG

  • Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
  • Review the Week 5 Focused Exam: Cough Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.
  • Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

Focused Exam: Cough Assignment:

Complete the following in Shadow Health:

  • Respiratory Concept Lab (Required)
  • Episodic/Focused Note for Focused Exam: Cough
  • HEENT (Recommended but not required)

Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve a total of 80% or better (this includes your DCE and your Documentation Notes), but you must take all attempts by the Week 5 Day 7 deadline.

Submission and Grading Information

By Day 7 of Week 5
  • Complete your Focused Exam: Cough DCE Assignment in Shadow Health via the Shadow Health link in Blackboard.
  • Once you complete your Assignment in Shadow Health, you will need to download your lab pass and upload it to the corresponding assignment in Blackboard for your faculty review.
  • (Note: Please save your lab pass as “LastName_FirstName_AssignmentName”.) You can find instructions for downloading your lab pass here:
  • Once you submit your Documentation Notes to Shadow Health, make sure to add your documentation to the Documentation Note Template and submit it into your Assignment submission link below.
  • Complete the Code of Conduct Acknowledgement.
Grading Criteria

To access your rubric:

Week 5 Assignment 2 DCE Rubric

Submit Your Assignment by Day 7 of Week 5

To submit your Lab Pass:

Week 5 Lab Pass

To participate in this Assignment:

Week 5 Documentation Notes for Assignment 2

To Submit your Student Acknowledgement:

 

Click here and follow the instructions to confirm you have complied with Walden University’s Code of Conduct including the expectations for academic integrity while completing the Shadow Health Assessment.

Assignment 2: Digital Clinical Experience:

Focused Exam: Cough

In this DCE Assignment, you will conduct a focused exam related to cough in your DCE
using the simulation tool, Shadow Health. You will determine what history should be
collected from the patient, what physical exams and diagnostic tests should be
conducted, and formulate a differential diagnosis with several possible conditions.
Photo Credit: Getty Images
To Prepare
 Review this week's Learning Resources and consider the insights they provide related
to ears, nose, and throat.
 Review the Shadow Health Resources provided in this week’s Learning Resources
specifically the tutorial to guide you through the documentation and interpretation within
the Shadow Health platform. Review the examples also provided.
 Review the DCE (Shadow Health) Documentation Template for Focused Exam: Cough
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 5 Focused Exam: Cough Rubric provided in the Assignment
submission area for details on completing the Assignment in Shadow Health.
 Consider what physical exams and diagnostic tests would be appropriate to gather
more information about the patient's condition. How would the results be used to make
a diagnosis?
Focused Exam: Cough Assignment:
Complete the following in Shadow Health:
 Respiratory Concept Lab (Recommended but not required)
  Episodic/Focused Note for Focused Exam: Cough
Note: Each Shadow Health Assessment may be attempted and reopened as many
times as necessary prior to the due date to achieve a total of 80% or better (this
includes your DCE and your Documentation Notes), but you must take all attempts by
the Week 5 Day 7 deadline.
Submission and Grading Information
By Day 7 of Week 5
 Complete your Focused Exam: Cough DCE Assignment in Shadow Health via the
Shadow Health link in Blackboard.
 Once you complete your Assignment in Shadow Health, you will need to download your
lab pass and upload it to the corresponding assignment in Blackboard for your faculty
review.
 (Note: Please save your lab pass as “LastName_FirstName_AssignmentName”.) You
can find instructions for downloading your lab pass
here: https://link.shadowhealth.com/download-lab-pass

 Once you submit your Documentation Notes to Shadow Health, make sure to copy and
paste the same Documentation Notes into your Assignment submission link below.
 Download, sign, date, and submit your Student Acknowledgement Form found in the
Learning Resources for this week.
Grading Criteria
To access your rubric:
Week 5 Assignment 2 DCE Rubric
Submit Your Assignment by Day 7 of Week 5
To submit your Lab Pass:
Week 5 Lab Pass
To participate in this Assignment:
Week 5 Documentation Notes for Assignment 2
To Submit your Student Acknowledgement Form:
Submit your Week 5 Assignment 2 DCE Student Acknowledgement Form

What's Coming Up in Week 6?

Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images
Next week, you will evaluate abnormal findings in the area of the abdomen and the
gastrointestinal system. In addition, you will appraise health assessment techniques and
diagnoses for the heart, lungs, and peripheral vascular system as you complete your
Lab Assignment in assessing the abdomen in a SOAP note format. You will also take
your Midterm Exam, which covers the topics in Weeks 1–6. Please review the previous
weekly content and resources to help you prepare for your exam. Plan your time
accordingly.
Week 6 Required Media
Photo Credit: [fergregory]/[iStock / Getty Images Plus]/Getty Images
Next week, you will need to view several videos and animations in the Seidel’s Guide to
Physical Examination as well as other media, as required, prior to completing your Lab
Assignment. There are several videos of various lengths. Please plan ahead to ensure
you have time to view these media programs to complete your Assignment on time.
Next Week
To go to the next week:
Week 6

Learning Resources

Required Readings (click to expand/reduce)
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Seidel's guide to physical examination: An interprofessional
approach (9th ed.). St. Louis, MO: Elsevier Mosby.

 Chapter 11, “Head and Neck”
This chapter reviews the anatomy and physiology of the head and neck.
The authors also describe the procedures for conducting a physical
examination of the head and neck.

 Chapter 12, “Eyes”
In this chapter, the authors describe the anatomy and function of the eyes.
In addition, the authors explain the steps involved in conducting a physical
examination of the eyes.

 Chapter 13, “Ears, Nose, and Throat”
The authors of this chapter detail the proper procedures for conducting a
physical exam of the ears, nose, and throat. The chapter also provides

pictures and descriptions of common abnormalities in the ears, nose, and
throat.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health
assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO:
Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., &
Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

Chapter 15, “Earache”
This chapter covers the main questions that need to be asked about the
patient’s condition prior to the physical examination as well as how these
questions lead to a focused physical examination.
Chapter 21, “Hoarseness”
This chapter focuses on the most common causes of hoarseness. It
provides strategies for evaluating the patient, both through questions and
through physical exams.
Chapter 25, “Nasal Symptoms and Sinus Congestion”

In this chapter, the authors highlight the key questions to ask about the
patients symptoms, the key parts of the physical examination, and
potential laboratory work that might be needed to provide an accurate
diagnosis of nasal and sinus conditions.
Chapter 30, “Red Eye”

The focus of this chapter is on how to determine the cause of red eyes in
a patient, including key symptoms to consider and possible diagnoses.
Chapter 32, “Sore Throat”

A sore throat is one most common concerns patients describe. This
chapter includes questions to ask when taking the patient’s history, things
to look for while conducting the physical exam, and possible causes for
the sore throat.
Chapter 38, “Vision Loss”
This chapter highlights the causes of vision loss and how the causes of
the condition can be diagnosed.

Note: Download the six documents (Student Checklists and Key Points)
below, and use them as you practice conducting assessments of the
head, neck, eyes, ears, nose, and throat.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Head and neck: Student checklist. In Seidel's guide to physical
examination: An interprofessional approach (9th ed.). St. Louis, MO:
Elsevier Mosby.
Credit Line: Seidel's Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the
Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., & Solomon, B. S., & Stewart, R. W.
(2019). Head and neck: Key points. In Seidel's guide to physical
examination: An interprofessional approach (9th ed.). St. Louis, MO:
Elsevier Mosby.
Credit Line: Seidel's Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the
Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Eyes: Student checklist. In Seidel's guide to physical examination:
An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel's Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the
Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Eyes: Key points. In Seidel's guide to physical examination: An
interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel's Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the
Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Ears, nose, and throat: Student checklist. In Seidel's guide to
physical examination: An interprofessional approach (9th ed.). St. Louis,
MO: Elsevier Mosby.
Credit Line: Seidel's Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the
Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Ears, nose, and throat: Key points. In Seidel's guide to physical
examination: An interprofessional approach (9th ed.). St. Louis, MO:
Elsevier Mosby.
Credit Line: Seidel's Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the
Copyright Clearance Center.

Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia,
PA: F. A. Davis.
Credit Line: Advanced practice nursing procedures, 1st Edition by Colyar, M. R. Copyright 2015 by F. A. Davis
Company. Reprinted by permission of F. A. Davis Company via the Copyright Clearance Center.

 Chapter 71, “Visual Function Evaluation: Snellen, Illiterate E, Pictorial

This section explains the procedural knowledge needed to perform eyes,
ears, nose, and mouth procedures.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.).
Philadelphia, PA: F. A. Davis.

 Chapter 2, "The Comprehensive History and Physical Exam" (Previously
read in Weeks 1, 3, 4, and 5)
Bedell, H. E., & Stevenson, S. B. (2013). Eye movement testing in clinical
examination. Vision Research 90, 32–37.
doi:10.1016/j.visres.2013.02.001. Retrieved from
https://www.sciencedirect.com/science/article/pii/S0042698913000217
Rubin, G. S. (2013). Measuring reading performance. Vision Research,
90, 43–51. doi:10.1016/j.visres.2013.02.015. Retrieved from
http://www.sciencedirect.com/science/article/pii/S0042698913000436

Harmes, K. M., Blackwood, R. A., Burrows, H. L., Cooke, J. M., Harrison,
R. V., & Passamani, P. P. (2013). Otitis media: Diagnosis and treatment.
American Family Physicians, 88(7), 435–440.

Otolaryngology Houston. (2014). Imaging of maxillary sinusitis (X-ray, CT,
and MRI). Retrieved from
http://www.ghorayeb.com/ImagingMaxillarySinusitis.html

This website provides medical images of sinusitis, including X-rays, CT
scans, and MRIs (magnetic resonance imaging).
Document: Episodic/Focused SOAP Note Exemplar (Word document)

Document: Episodic/Focused SOAP Note Template (Word document)

Document: Midterm Exam Review (Word document)
Shadow Health Support and Orientation Resources
Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file].
Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY
Shadow Health. (n.d.). Shadow Health help desk. Retrieved
from https://support.shadowhealth.com/hc/en-us
Document: Shadow Health. (2014). Useful tips and tricks (Version 2)
(PDF)
Document: Student Acknowledgement Form (Word document)
Note: You will sign and date this form each time you complete your DCE
Assignment in Shadow Health to acknowledge your commitment to
Walden University’s Code of Conduct.
Document: DCE (Shadow Health) Documentation Template for Focused
Exam: Cough (Word document)
Use this template to complete your Assignment 2 for this week.

Optional Resource
Use the following resources to guide you through your Shadow Health orientation
as well as other support resources:
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s
diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.

 Chapter 7, “The Head and Neck” (pp. 178–301)

This chapter describes head and neck examinations that can be made
with general clinical resources. Also, the authors detail syndromes of
common head and neck conditions.
Required Media (click to expand/reduce)
Online media for Seidel's Guide to Physical Examination
It is highly recommended that you access and view the resources included with
the course text, Seidel's Guide to Physical Examination. Focus on the videos and
animations in Chapters 10, 11, and 12 that relate to the assessment of the head,

neck, eyes, ears, nose, and throat. Refer to the Week 4 Learning Resources
area for access instructions on https://evolve.elsevier.com/.
University of Iowa Ophthalmology. (2016, December 19). Fluorescein
staining of the cornea. Retrieved from https://vimeo.com/198695974
Credit Line: University of Iowa Ophthalmology. (n.d.). Fluorescein staining of the cornea [Video file]. Retrieved from
​https://vimeo.com/198695974. The author(s) and publishers acknowledge the University of Iowa and EyeRounds.org
for permission to reproduce this copyrighted material.

Note: Approximate length of this media program is 25 seconds.

 

Rubric Detail

Select Grid View or List View to change the rubric’s layout.

Name: NURS_6512_Week_5_DCE_Assignment_2_Rubric
Description: To complete the Shadow Health assignments, it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions and the physical assessment areas. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Weeks 1 and 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score.
Grid View
List View
Excellent Good Fair Poor
Student DCE score

(DCE percentages will be calculated automatically by Shadow Health after the assignment is completed.)

Note: DCE Score – Do not round up on the DCE score.
56 (56%) – 60 (60%)
DCE score>93
51 (51%) – 55 (55%)
DCE Score 86-92
46 (46%) – 50 (50%)
DCE Score 80-85
0 (0%) – 45 (45%)
DCE Score <79

No DCE completed.
Subjective Documentation in Provider Notes

Subjective narrative documentation in Provider Notes is detailed and organized and includes:

Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS)

ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each system as follows:
General: Head: EENT: etc. Assignment 2 Digital Clinical Experience Focused Exam Cough NURS 6512N-32.PNG

You should list these in bullet format and document the systems in order from head to toe.
16 (16%) – 20 (20%)
Documentation is detailed and organized with all pertinent information noted in professional language.

Documentation includes all pertinent documentation to include Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).
11 (11%) – 15 (15%)
Documentation with sufficient details, some organization and some pertinent information noted in professional language.

Documentation provides some of the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).
6 (6%) – 10 (10%)
Documentation with inadequate details and/or organization; and inadequate pertinent information noted in professional language.

Limited or/minimum documentation provided to analyze students critical thinking abilities for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).
0 (0%) – 5 (5%)
Documentation lacks any details and/or organization; and does not provide pertinent information noted in professional language.

No information is provided for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).

or

No documentation provided.
Objective Documentation in Provider Notes – this is to be completed in Shadow Health

Physical exam: Document in a systematic order starting from head-to-toe, include what you see, hear, and feel when doing your physical exam using medical terminology/jargon. Document all normal and abnormal exam findings. Do not use “WNL” or “normal”.

You only need to examine the systems that are pertinent to the CC, HPI, and History.

Diagnostic result – Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned

Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1).
16 (16%) – 20 (20%)
Documentation detailed and organized with all abnormal and pertinent normal assessment information described in professional language.

Each system assessed is clearly documented with measurable details of the exam.
11 (11%) – 15 (15%)
Documentation with sufficient details and some organization; some abnormal and some normal assessment information described in mostly professional language.

Each system assessed is somewhat clearly documented with measurable details of the exam.
6 (6%) – 10 (10%)
Documentation with inadequate details and/or organization; inadequate identification of abnormal and pertinent normal assessment information described; inadequate use of professional language.

Each system assessed is minimally or is not clearly documented with measurable details of the exam.
0 (0%) – 5 (5%)
Documentation with no details and/or organization; no identification of abnormal and pertinent normal assessment information described; no use of professional language.

None of the systems are assessed, no documentation of details of the exam.

or

No documentation provided.
Total Points: 100
Name: NURS_6512_Week_5_DCE_Assignment_2_Rubric
Description: To complete the Shadow Health assignments, it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions and the physical assessment areas. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Weeks 1 and 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score.

NURS_6512_Week_5_DCE_Assignment_2_Rubric

Description: To complete the Shadow Health assignments, it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions and the physical assessment areas. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Weeks 1 and 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score.

Excellent Good Fair Poor
Student DCE score

(DCE percentages will be calculated automatically by Shadow Health after the assignment is completed.)

Note: DCE Score – Do not round up on the DCE score.

Points Range: 56 (56%) – 60 (60%)
DCE score>93
Points Range: 51 (51%) – 55 (55%)
DCE Score 86-92
Points Range: 46 (46%) – 50 (50%)
DCE Score 80-85
Points Range: 0 (0%) – 45 (45%)
DCE Score <79

No DCE completed.

Subjective Documentation in Provider Notes

Subjective narrative documentation in Provider Notes is detailed and organized and includes:

Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS)

ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each system as follows:
General: Head: EENT: etc.

You should list these in bullet format and document the systems in order from head to toe.

Points Range: 16 (16%) – 20 (20%)
Documentation is detailed and organized with all pertinent information noted in professional language.

Documentation includes all pertinent documentation to include Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).

Points Range: 11 (11%) – 15 (15%)
Documentation with sufficient details, some organization and some pertinent information noted in professional language.

Documentation provides some of the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).

Points Range: 6 (6%) – 10 (10%)
Documentation with inadequate details and/or organization; and inadequate pertinent information noted in professional language.

Limited or/minimum documentation provided to analyze students critical thinking abilities for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).

Points Range: 0 (0%) – 5 (5%)
Documentation lacks any details and/or organization; and does not provide pertinent information noted in professional language.

No information is provided for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).

or

No documentation provided.

Objective Documentation in Provider Notes – this is to be completed in Shadow Health

Physical exam: Document in a systematic order starting from head-to-toe, include what you see, hear, and feel when doing your physical exam using medical terminology/jargon. Document all normal and abnormal exam findings. Do not use “WNL” or “normal”.

You only need to examine the systems that are pertinent to the CC, HPI, and History.

Diagnostic result – Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned

Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1).

Points Range: 16 (16%) – 20 (20%)
Documentation detailed and organized with all abnormal and pertinent normal assessment information described in professional language.

Each system assessed is clearly documented with measurable details of the exam.

Points Range: 11 (11%) – 15 (15%)
Documentation with sufficient details and some organization; some abnormal and some normal assessment information described in mostly professional language.

Each system assessed is somewhat clearly documented with measurable details of the exam.

Points Range: 6 (6%) – 10 (10%)
Documentation with inadequate details and/or organization; inadequate identification of abnormal and pertinent normal assessment information described; inadequate use of professional language.

Each system assessed is minimally or is not clearly documented with measurable details of the exam.

Points Range: 0 (0%) – 5 (5%)
Documentation with no details and/or organization; no identification of abnormal and pertinent normal assessment information described; no use of professional language.

None of the systems are assessed, no documentation of details of the exam.

or

No documentation provided.

Total Points: 100
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