Documentation / Electronic Health Record · Documentation Vitals Student Documentation Model Documentation Vitals Ms. Tina Jones vital signs are as follows: Temperature=37.2C (98.9F), HR=78, RR=15, B/P=128/83, Sa02=99%, Wt:90kg (198lbs), Ht: 5'7", Spirometry= FVC 1.78L, FEV1=1.549L. N/A Health History Student Documentation Model Documentation Identifying Data & Reliability Ms. Joes is 28 years old African-American female who visited the clinic for pre-employment physical. She is responsible for self, and able to give history information of self freely without hesitation. she is religious, single, educated, likes to go out with her friends. Her occupation is Smith, Stevens, Stewart, Silver & Company. N/A General Survey Ms. Jones alert and oriented x4, to person, place, time and situation. she is aware of her diagnosis. She is well groomed and dressed appropriately, looked well nourished, well developed and has very good hygiene. She answered questions appropriately without hesitation. she seated well upright in the examination table. N/A Reason for Visit Ms. Jones visit is for pre-employment physical. N/A History of Present Illness Ms. Jones stated that she has recently got a job at new place and she is supposed to provide a physical examination. Ms. Jones did not voice any acute concerns. The gynecologist diagnosed her with polycystic ovary syndrome (PCOS). She was prescribed oral contraceptives that helped improve her acne. She has history of diabetes and asthma. And she stated that she has modified her lifestyle habit. N/A Medications Metformin 850 mg PO BID, Flovent 110 mcg/spray, albuterol 90 mcg/spray MDI 1 to 3 puffs every 4 hours as needed. Tylenol 500 to 1000 mg PO PRN for headaches, ibuprofen 600 mg PO TID PRN for menstrual cramps. N/A Allergies Ms. Jones is allergic to penicillin (PNC), cats, dust. Denies food and latex allergies. N/A Medical History Ms. Jones was diagnosed with asthmas when she was 2 and half years old, and the she had asthma attack 3 months ago. She was diagnosed with diabetes when she was 24 years of age. she was diagnosed with PCOS 4 months ago, and N/A Health Maintenance She had pap smears 4 months ago, had eye examination 3 months ago, had dental checkup 5 months ago. Abide by the car seat belt by putting seat on while driving. She uses sun screen to prevent sun burnt, PPD was done 2 years ago and it was negative. N/A Family History Ms. Jones stated that her maternal grand-mother died of stroke, history of hypertension and high cholesterol, at age 75. Maternal grand-father died of stroke, hypertension and high cholesterol at age of 78. Paternal grand-father died of colon cancer at age 65, also had type 2 diabetes. Paternal uncle died suddenly of cancer, kidney disease, sickle cell anemia and thyroid problems. Paternal grand-mother is 82 years old and still living, and she has hypertension. N/A Social History Ms. Jones is currently living with her mother and her sister, but had lived independently since she was ...

1. Documentation / Electronic Health Record
· Documentation
Vitals
Student Documentation
Model Documentation
Vitals
Ms. Tina Jones vital signs are as follows: Temperature=37.2C
(98.9F), HR=78, RR=15, B/P=128/83, Sa02=99%, Wt:90kg
(198lbs), Ht: 5'7", Spirometry= FVC 1.78L, FEV1=1.549L.
N/A
Health History
Student Documentation
Model Documentation
Identifying Data & Reliability
Ms. Joes is 28 years old African-American female who visited
the clinic for pre-employment physical. She is responsible for
self, and able to give history information of self freely without
hesitation. she is religious, single, educated, likes to go out with
her friends. Her occupation is Smith, Stevens, Stewart, Silver &
Company.
N/A
General Survey
Ms. Jones alert and oriented x4, to person, place, time and
situation. she is aware of her diagnosis. She is well groomed
and dressed appropriately, looked well nourished, well
developed and has very good hygiene. She answered questions
appropriately without hesitation. she seated well upright in the
examination table.
N/A
Reason for Visit
Ms. Jones visit is for pre-employment physical.
N/A
History of Present Illness
Ms. Jones stated that she has recently got a job at new place and

2. she is supposed to provide a physical examination. Ms. Jones
did not voice any acute concerns. The gynecologist diagnosed
her with polycystic ovary syndrome (PCOS). She was
prescribed oral contraceptives that helped improve her acne.
She has history of diabetes and asthma. And she stated that she
has modified her lifestyle habit.
N/A
Medications
Metformin 850 mg PO BID, Flovent 110 mcg/spray, albuterol
90 mcg/spray MDI 1 to 3 puffs every 4 hours as needed. Tylenol
500 to 1000 mg PO PRN for headaches, ibuprofen 600 mg PO
TID PRN for menstrual cramps.
N/A
Allergies
Ms. Jones is allergic to penicillin (PNC), cats, dust. Denies food
and latex allergies.
N/A
Medical History
Ms. Jones was diagnosed with asthmas when she was 2 and half
years old, and the she had asthma attack 3 months ago. She was
diagnosed with diabetes when she was 24 years of age. she was
diagnosed with PCOS 4 months ago, and
N/A
Health Maintenance
She had pap smears 4 months ago, had eye examination 3
months ago, had dental checkup 5 months ago. Abide by the car
seat belt by putting seat on while driving. She uses sun screen
to prevent sun burnt, PPD was done 2 years ago and it was
negative.
N/A
Family History
Ms. Jones stated that her maternal grand-mother died of stroke,
history of hypertension and high cholesterol, at age 75.
Maternal grand-father died of stroke, hypertension and high
cholesterol at age of 78. Paternal grand-father died of colon
cancer at age 65, also had type 2 diabetes. Paternal uncle died

3. suddenly of cancer, kidney disease, sickle cell anemia and
thyroid problems. Paternal grand-mother is 82 years old and
still living, and she has hypertension.
N/A
Social History
Ms. Jones is currently living with her mother and her sister, but
had lived independently since she was 19 years old. She will be
moving to her own place in one month. she will be starting her
new job in two weeks’ time at Smith, Stevens, Stewart, Silver,
& Company. She and her friends started a book club and read
one book each month. She goes to bible study, go to talks at
church, watch science documentary on TV sometimes when she
is alone. she reported no drug any kind used, she stated that she
had smoked marijuana when she was young, and never smoked
cigarette. She drinks alcohol occasionally when she is out with
her friends. Her breakfast is smoothie made with frozen fruit
and yogurt, lunch sandwich on wheat bread, then for dinner is
chicken of fish with vegetables and brown rice or quinoa. she
denied drinking coffee, but drinks diet soda occasionally, i to 2
soda per day. she takes a walk 4 to 5 time a week with yoga and
swimming incorporated. She has gone outside the country
recently. And she does not have any pets.
N/A
Mental Health History
Ms. Jones is very alert and oriented x 4, to person, place, time,
and situation. She is well groomed and responded appropriately
to questions without difficulties, very cooperative, also focused
and engaged in the conversation. Denied any feeling of
depression, less stress, no anxiety, no suicidal thoughts. She
reported sleeping better with good coping abilities and decrease
stress. She seems very pleasant, speech flows and clear, no tics
or any facial fasciculation.
N/A
Review of Systems - General
Ms. Jones did not report any recent health problems, no fever,
no chills, no tiredness, no night sweats. Ms. Jones stated that

4. she has change her diet and exercise more, and has lost 10lbs in
the process.
N/A
HEENT
Student Documentation
Model Documentation
Subjective
Ms. Jones stated that she has no headache currently, and no
history of head injury, no change in visual. She said that she has
no eye pain, no itchy eyes, no redness, no dry eyes noted. She
wears corrective glasses, and last eye checkup was 3 months
ago. No hearing or ear problems noted, no ear pain or discharge
noted. She said there is no change in the sense of smell, nose
sneezing, no sinus pain or pressure noted, epistaxis, and no
rhinorrhea noted. She denied mouth and gum problems, no
change in taste, no dry mouth, no sore and no pain noted. The
tongue is pink and moist without lesions, no pain to the jaw.
Stated no dental issues and had dental checkup 5 months ago.
She said that she has no problem swallowing, no sore throat, no
change in voice and no swollen nodes noted.
N/A
Objective
Head is normocephalic, no trauma, scalp full of hair and hair
line is well distributed. Equal hair distribution on the eye lashes
bilaterally, eye brows and eyelids without lesions, no eye
dropping or edema noted. The conjunctiva is pink without any
lesions and the sclera is white. Eyes reacted to light, PERRLA
bilaterally. Bilateral EOMs intact, no nystagmus. Noted mild
retinopathic changes on the right eye, left fundus is with sharp
disc margins, and no hemorrhages noted. Performed Snelling
test and the right eye is 20/20, and the left eye is 20/20, and she
wears glasses which is a corrective lens. The ITM is intact
bilaterally and pearly gray. Whispered words heard bilaterally.
No tenderness noted on frontal and maxillary sinuses upon
palpation. Both nasal and oral mucosa are pink and moist
without ulceration or any lesions noted, and the uvula ri ses in

5. the middle on phonation. Gag reflex good and intact, no dental
issue noted, no infection. The tonsils were 2+ bilaterally,
thyroid is smooth without nodules, no goiter noted, and no
palpable lymph nodes.
N/A
Respiratory
Student Documentation
Model Documentation
Subjective
Ms. Jones stated that she has asthma and uses inhaler for
management. She said there is no current breathing issues. She
also stated that occasionally she experiences shortness of
breath, wheezing and chest tightness.
N/A
Objective
Ms. Jones chest wall is symmetrical with respiration upon
auscultation clear bilaterally. No coughing or wheezing noted.
It resonates to percussion all around.
N/A
Cardiovascular
Student Documentation
Model Documentation
Subjective
Ms. Jones reported no palpations, no heart raising (tachycardia),
stated no bruises, but may have had one or two in the past six
month., and no sign and symptom of edema reported.
N/A
Objective
Ms. Jones heart rate is regular, S1 and S2 indicated no
murmurs, no gallops, no friction robs. Bilateral carotids arteries
are equal bilaterally upon auscultation without bruit. PMI at the
midclavicular line, 5th intercostal space, there no heaves or any
lifts noted. Bilateral peripheral pulse is present, no peripheral
edema noted. Capillary refill is less than 3 seconds.
N/A
Abdominal

6. Student Documentation
Model Documentation
Subjective
For gastrointestinal, Ms. Jones denied nausea and vomiting, no
constipation, no diarrhea, no bloating and no food intolerance.
She denied dysuria, nocturia, polyuria, hematuria, no flank pain
verbalized, denied vaginal discharge or itching.
N/A
Objective
Ms. Jones is observed with no protrusion and the abdomen is
symmetrical without any visible masses, scars, or any lesions on
the body, hair observed from the pubic area to the umbilicus.
Bowel sounds positive and normoactive in all 4 quadrants.
Noted tympanic on all percussion. No tenderness, no guarding
and no distension noted upon palpation. No tenderness to CVA,
and organ enlargement palpated.
N/A
Musculoskeletal
Student Documentation
Model Documentation
Subjective
Ms. Jones denied having any joint pain, muscle pain, muscle
weakness, and no swelling.
N/A
Objective
No swollen noted on bilateral upper and lower extremities, no
sign of deformities or any masses noted. She is able perform
range of motion without any complaints of pain during
movement.
N/A
Neurological
Student Documentation
Model Documentation
Subjective
Ms. Jones stated that she has not have any headaches, no light-
headedness, no tingling, no seizure, no loss of coordination and

7. no disability.
N/A
Objective
Ms. Jones is noted with strength is 5/5 both upper and lower
extremities. She has normal graphesthesia, stereognosis and
alternating the movements bilaterally rapidly. Test of the
cerebellar function is normal. Noted decrease sensation to
monofilament in the bilateral planter surfaces. Deep Tendon
Reflexes is 2+ (DTRS) and equal bilaterally to the upper and
lower extremities.
N/A
Skin, Hair & Nails
Student Documentation
Model Documentation
Subjective
Ms. Jones stated, "I still get zits but my acne is better than it
used to be". She said that the birth control medicine is helping
with the acne and the skin on her neck. she said sha has moles
on her back and nothing seems different about them. She also
said that the facial and body hair has improved, and denied any
nails and hair changes.
N/A
Objective
Ms. Jones is noted with rashes on the face, facial hair on the
upper lip, darkened skin around her neck.
N/A
Mental Health Nursing
Interpersonal Process Recording (IPR)
Student Name: Fatumata Wongbay
Date: 07/16/21
Brief information about this

8. client________________________________________________
___________________________________________
Student Goal for this
interaction____________________________________________
________________________________________________
Setting/Time:_________________________________________
_____________________________________________________
_____________
Nurse Communication
(Verbal & Non-verbal)
Client communication
(Verbal & Non-verbal)
Nurse’s Thoughts &
Feelings Related to the
Interaction
Communication Technique
(Therapeutic/Non-Therapeutic)
Alternative or Revised Response
1.
2.

9. 3.
4.
5.
6.
7.
8.

10. 9.
Nurse Communication
(Verbal & Non-verbal)
Client communication
(Verbal & Non-verbal)
Nurse’s Thoughts &
Feelings Related to the
Interaction
Communication Technique
(Therapeutic/Non-Therapeutic)
Alternative or Revised Response
10.
11.

11. 12.
13.
14.
15
16.
17.

12. 18.
19.
20.
Week 9
Shadow Health Comprehensive SOAP Note Template
Patient Initials: _______ Age: _______
Gender: _______
SUBJECTIVE DATA:
Chief Complaint (CC):
History of Present Illness (HPI):

13. Medications:
Allergies:
Past Medical History (PMH):
Past Surgical History (PSH):
Sexual/Reproductive History:
Personal/Social History:
Health Maintenance:
Immunization History:
Significant Family History:
Review of Systems:
General:
HEENT:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Neurological:
Psychiatric:
Skin/hair/nails:
OBJECTIVE DATA:
Physical Exam:

14. Vital signs:
General:
HEENT:
Neck:
Chest/Lungs:
Heart/Peripheral Vascular:
Abdomen:
Genital/Rectal:
Musculoskeletal:
Neurological:
Skin:
Diagnostic results:
ASSESSMENT:
PLAN: This section is not required for the assignments in this
course (NURS 6512), but will be required for future courses.
© 2021 Walden University, LLC
Page 2 of 3
Rubric Detail
Select Grid View or List View to change the rubric's layout.
Content
Name: NURS_6512_Week_9_DCE_Assignment_3_Rubric
Description: Note: 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. Review the Advanced Health Assessment
Nursing Documentation Tutorial located in the Week 4
Resources, the model documentation in Shadow Health, as well
as sample documentation in the text to assist with narrative

15. documentation of the assessments. Do not copy any sample
documentation as this is plagiarism.
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. You must pass this assignment with a total
cumulative score of 79.5% or greater in order to pass this
course.
Grid ViewList 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.
Points:

16. Points Range:
56 (56%) - 60 (60%)
DCE score>93
Feedback:
Points:
Points Range:
51 (51%) - 55 (55%)

17. DCE Score 86-92
Feedback:
Points:
Points Range:
46 (46%) - 50 (50%)

18. DCE Score 80-85
Feedback:
Points:
Points Range:
0 (0%) - 45 (45%)

19. DCE Score <79
No DCE completed.
Feedback:
Documentation in Provider Notes Area
Subjective documentation of the comprehensive exam in
Provider Notes is detailed, organized, and includes
documentation of identifying data, general survey, reason for
visit/chief complaint, history of present illness, medications,
allergies, medical history, health maintenance, family history,
social history, mental health history, and review of systems.
The review of systems is clearly defined by each body system
(skin, eyes, cardiac, etc.) and all conditions or illnesses asked
of the patient are documented along with the patient response.

20. Points:
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).
Feedback:

21. Points:
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).
Feedback:

22. Points:
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).

23. Feedback:
Points:
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,

24. Current Medications, Allergies, Past Medical History, Family
History, Social History and Review of Systems (ROS).
or
No documentation provided.
Feedback:
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".
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).

25. Points:
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.
Feedback:

26. Points:
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.
Feedback:

27. Points:
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.

28. Feedback:
Points:
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

29. of the exam.
or
No documentation provided.
Feedback:
Show Descriptions
Show Feedback
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.--

30. Levels of Achievement:
Excellent
56 (56%) - 60 (60%)
DCE score>93
Good
51 (51%) - 55 (55%)
DCE Score 86-92
Fair
46 (46%) - 50 (50%)
DCE Score 80-85
Poor
0 (0%) - 45 (45%)

31. DCE Score <79
No DCE completed.
Feedback:
Documentation in Provider Notes Area
Subjective documentation of the comprehensive exam in
Provider Notes is detailed, organized, and includes
documentation of identifying data, general survey, reason for
visit/chief complaint, history of present illness, medications,
allergies, medical history, health maintenance, family history,
social history, mental health history, and review of systems.
The review of systems is clearly defined by each body system
(skin, eyes, cardiac, etc.) and all conditions or illnesses asked
of the patient are documented along with the patient response.--
Levels of Achievement:
Excellent

32. 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).
Good
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).
Fair
6 (6%) - 10 (10%)

33. 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).
Poor
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.
Feedback:

34. 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".
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).--
Levels of Achievement:
Excellent
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

35. details of the exam.
Good
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.
Fair
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.
Poor

36. 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.
Feedback:
Total Points:
100

37. Name: NURS_6512_Week_9_DCE_Assignment_3_Rubric
Description: Note: 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. Review the Advanced Health Assessment
Nursing Documentation Tutorial located in the Week 4
Resources, the model documentation in Shadow Health, as well
as sample documentation in the text to assist with narrative
documentation of the assessments. Do not copy any sample
documentation as this is plagiarism.
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. You must pass this assignment with a total
cumulative score of 79.5% or greater in order to pass this
course.