DIGITAL CLINICAL EXPERIENCE: COMPREHENSIVE (HEAD-TO-TOE) PHYSICAL ASSESSMENT

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Throughout this course, you were encouraged to practice conducting various physical assessments on multiple areas of the body, ranging from the head to the toes. Each of these assessments, however, was conducted independently of one another. For this DCE Assignment, you connect the knowledge and skills you gained from each individual assessment to perform a comprehensive head-to-toe physical examination in your Digital Clinical Experience.

TO PREPARE

  • 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 TemplateDownload Week 9 Shadow Health Comprehensive SOAP Note Documentation Template

Required Readings

  • Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). St. Louis, MO: Elsevier Mosby.
    • Chapter 7, “Mental Status”
      This chapter revolves around the mental status evaluation of an individual’s overall cognitive state. The chapter includes a list of mental abnormalities and their symptoms.
    • Chapter 23, “Neurologic System”
      The authors of this chapter explore the anatomy and physiology of the neurologic system. The authors also describe neurological examinations and potential findings.
  • 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.
  • Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
    • Chapter 2, “The Comprehensive History and Physical Exam” (“Cranial Nerves and Their Function” and “Grading Reflexes”) (Previously read in Weeks 1, 2, 3, and 5)
  • O’Caoimh, R., & Molloy, D. W. (2019). Comparing the diagnostic accuracy of two cognitive screening instruments in different dementia subtypes and clinical depression.Links to an external site. Diagnostics, 9(3), 93. https://doi.org/10.3390/diagnostics9030093

Use the following resources to guide you through your Shadow Health orientation as well as other support resources:

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