College of Nursing

UNIVERSITY OF WISCONSIN-MILWAUKEECOLLEGE OF NURSING

Graduate Course Syllabus

Spring 2015

Title: NURS 754: COMPREHENSIVE ASSESSMENT OF HEALTH:

IMPLICATIONS FOR CLINICAL DECISION MAKING

Credits: 3 units; GComprehensive Assessment of Health: Implications for Clinical Decision Making. it is a graduate level 3-credit course. The lecture portion of the course is 2 credits, and the co-requisite laboratory is 1 credit (2 contact hours).

Prerequisites: Grad st; admis to Nursing degree program; Nurs 753(P); or cons instr. Enroll in LEC 401 & LAB 802 or 803.

Faculty: Dr. James Bockeloh, DNP, RN, FNP-BC, APNP e-mail: bockeloh@uwm.edu Office: Cunningham 522 UWM Ph#414 229-5556 Cell Ph# 262-880-6415Office Hours: By Appointment

Lab Instructors: Kristen R. Swanson MSN APNPEmail swansokr@uwm.eduCell 414.312.2773

Program Director : Dr. Julie Darmody, Ph.D., RN, ACNS-BSEmail: darmodyj@uwm.eduOffice: (414) 229-5558Cunningham Hall 691

Class meetings times and location:

Lecture: Meets 5:00-6:50 PM Tues 01/26/15 – 05/07/15, CUN G40

LAB: 802: Meets 3:00 – 4:50 PM Tues 01/26/15 – 05/07/15, CUN NLRC

803: Meets 7:00-8:50 PM Tues 01/26/15 – 05/07/15, CUN NLRC

College of Nursing

Catalog Description: Comprehensive assessment of health in individuals and aggregates, including measurement of health status, appraisal of needs, analysis of environmental contexts, and development of diagnostic strategies.

Course Description: This course is designed to provide an in-depth analysis of approaches to the assessment of health in individuals, families, and populations. Emphasis will be placed on theories, research findings, and practice guidelines as they relate to measurement of health status, appraisal of health needs and concerns, analysis of environmental contexts, and clinical decision-making.

Course Objectives: Upon successful completion of the course, the student will be able to:

1. Apply selected theories, research, and clinical practice guidelines related to health assessment and diagnostic strategies.

2. Evaluate the health status of individuals and populations, synthesizing data derived through various health assessment strategies, including clinical status, cultural beliefs and behaviors, and environmental factors.

3. Demonstrate advanced assessment of health status of individuals across the lifespan, using comprehensive and focused approaches.

Textbooks and Readings:

Required: Goolsby, M., Grubbs, L. (2011). Advanced assessment: Interpreting findings and formulating

differential diagnoses. Philadelphia: F. A. Davis.

A physical assessment text. We suggest:

Ball, J.W., Dains, J.E., Flynn, J.A., Solomon, B.S., Stewart, R.W. (2014), Seidel's Guide to Physical Examination, 8e (Mosby's Guide to Physical Examination (Seidel))

* Shadow Healthcare Digital Clinical Experience Program Information.

Digital Clinical Experience [Computer software]. Gainesville, FL: Shadow Health.

Student Account Setup

Students can create their accounts by visiting http://app.shadowhealth.com/and enroll with this course-specific PIN: January2015-6866-4705-0836-7347

College of Nursing

* For registration and purchase, follow the guide at https://shadow.desk.com/customer/portal/articles/980991-how-to-register-with-shadow-health. You will need to copy and paste the unique PIN above to register in your fall course.

* Shadow Health recommends using headphones to access the concept labs in which you will practice identifying normal and abnormal sounds.

* Technical Requirements - http://bit.ly/Shadow_Requirements

* After registering, access Shadow Health assignment at app.shadowhealth.com

Recommended:

If you do not already have a current handbook for diagnostic testing, we recommend purchasing one for this course and for your upcoming clinical experiences.

Agency for Healthcare Research and Quality. (2008). Guide to clinical preventative services. Rockville, MD, AHRQ. Can be accessed online at: http://www.ahrq.gov/clinic/pocketgd1011/pocketgd1011.pdf

Seidel (Ed.)(2011). Mosby's physical examination handbook (7rd ed.). St. Louis: Mosby.

Wright, W. (2008). Physical Assessment & Health History of the Adult Examination (6h ed.).

North Andover, MA: Fitzgerald Health Education Associates. (can be found at www.FHEA.com)

There is also a wealth of assessment information and tools available online and in the 3rd floor NLRC. (We will discuss some of the available on-line resources in class).

Assignments and Evaluation:

1. Evaluation/Grading Your course grade will be based on both lecture and laboratory evaluations. The evaluation components will consist of the following:

Focused health & aggregate assessment presentation (25 points) Graded case studies & documentation (2 @ 10 points each=20 points) Observed performance of a focused physical examination (30 points) Shadow Health On Line Assessment Exercises (25 points) Total Course Grade = 100 points

2. Description of assignments .

College of Nursing

Focused Health and Aggregate Assessment Presentation

Students will be required to work in small groups (3-4 people) to research and write up a common “focused” clinical problem. This focused assessment will include pertinent history and physical examination findings, proposed diagnostic testing and a prioritized list of differential diagnoses. Students will also provide pertinent background, aggregate and epidemiological information about the problem. This assignment is preparation for the practical final examination and will be evaluated using the Scoring Guide: Focused Assessment. 5 points will be deducted for students who do not participate in the class presentation activity.

Practice Component

On-campus laboratory experiences will emphasize skills necessary for assessing the most commonly encountered health problems/conditions in clinical settings and for delivering preventive, curative, and rehabilitative services. The packet Scoring Guides for Health Assessment provides tools for you to use in practicing and faculty to use in evaluating assessment skills.

Students will have opportunity to obtain feedback on their advanced health assessment skills under the direct supervision of a faculty member during your clinical laboratory sessions. The laboratory will include the following activities:

Observed basic physical examination. In order to continue with the in-depth comprehensive assessment, students must demonstrate that they can do a basic head to toe examination within 20 minutes. This will be completed after the second lab session, and will be practiced during the first two lab sessions. The grading tool “BASIC ADULT PHYSICAL EXAMINATION: Observed” is found in the “Scoring Guides” portion of this packet. Students may bring one index card with notes on one side for reference during the test if they choose. Students must satisfactorily complete at least 83% of the components to pass. An unsatisfactory performance (<83%) will require students to practice and repeat the PE. The student who does not pass the examination on first attempt is responsible for his/her own remediation, but resources are available in the NLRC. Students who are unable to complete the basic physical examination upon the 2nd attempt will meet with Dr. Bockeloh to determine if they should continue in the advanced assessment course.

Case studies & Documentation. This course will use multiple case studies to integrate students’ previous clinical knowledge with Advance Practice Nurse level critical thinking, history taking and documentation skills. Students will have multiple case studies to choose from, work through during lab and document using SOAP format. Although two write-ups will be graded, students are encouraged to present practice write-ups to their lab instructor for critique of history taking and documentation skills and recommendations for improvement (if any). Critiqued documentation may not be submitted for a grade. Write-ups to be graded should be uploaded to the course D2L site drop box under the lab instructor’s name by the due date. Late case studies will receive one letter grade lower for each week they are late (A to A-; A-to B+).

Gynecological-genitourinary training. A training session with professional patients will occur during lab time towards the end of the semester in order to learn how to perform the female gynecological examination and a male genitourinary/rectal examination. For each examination, you

College of Nursing

will work in small groups with one course faculty and a professional patient. You will have an opportunity to perform the examination with the coaching and guidance of the faculty and the professional patient and to observe 2-3 other examinations.

Practical final assessment. Near the end of the semester, students will schedule a 20-minute time slot with their lab instructor for their lab final physical exam. Students will be given a scenario and be asked to perform a focused assessment, eliciting pertinent history and completing exam components appropriate to the patient’s clinical presentation. This exam utilizes professional patient models, with whom the student will interact and examine. Students must also select diagnostic tests to be done and provide a list of differential diagnoses in their documentation, no other treatment plans will be required.

Shadow Health Care On Line Digital Clinical Experience (DCE). The Shadow Health™ Digital Clinical Experience™ (DCE) provides a dynamic, immersive experience designed to improve your skills and clinical reasoning through the examination of digital standardized patients. Although these patients are digital, each one breathes, speaks, and has a complex medical and psychosocial history. We will be completing Shadow Health assignments throughout the course.

You can explore concept labs for the Respiratory, Cardiovascular, and Abdominal systems. We will be using these concept labs you students to review the anatomy of each system and practice identifying normal and abnormal sounds. You will complete these assignments after reviewing course content, reading the course textbook, and attending lecture.

With Tina Jones, you can practice taking a detailed health history and performing physical assessments in system-by-system assignments. All of these assignments take place during a single visit for Tina that begins at 8 a.m. We will be using these assignments to practice relevant skills and apply content knowledge prior to our hands-on practice sessions or lab. You will complete these assignments after reviewing course content, reading the course textbook, attending lecture, and completing the concept lab if applicable.

The focused exams allow you to respond to patients’ chief complaints. You will perform focused exams in which you will demonstrate a mastery of skills relevant to multiple body systems and professional communication. The Shadow Health DCE is worth 15 points of the final course grade.

3. Grading Scale :

95-100 A 87-90 B 79-82 C 72-74 D

93-94 A- 85-86 B- 77-78 C- 70-71 D-

91-92 B+ 83-84 C+ 75-76 D+ 00-69 F

4. Course Attendance Policy : Because the lectures/discussions and other types of class sessions are critical components of successfully completing the course, attendance is required. If you will be absent from class, please notify the course coordinator and or the lab instructor in advance as soon as possible. If you will miss a class, it is recommended that

College of Nursing

you arrange to have a classmate take notes for you and/or collect any handouts.

5. Course Expectations :

A. Required ReadingsStudents will be expected to complete all assigned readings from the textbooks prior to class. Students will be expected to read any additional assigned articles and online national practice guidelines as specified as well.

B. Grading PolicyAny assignment that is submitted after the due date according to the class schedule

will be reduced by one letter grade (e.g., A- to B+) for each week, including the first week that the assignment is late.

Content Outline and Assigned Readings

Week 1, Jan 27:

Lecture: Overview of class, Assessment of Individuals, Aggregates & Communities; Data Resources

Lab: Intro to lab, Basic PE review/practice.

Pre-Class Prep: Read assessment text & Goolsby chapters re: assessment/clinical decision making and documentation.

Week 2, Feb 3:

Lecture: Clinical Decision-Making, Diagnostics and Documentation; Focused assessment presentation topics will be assigned in class

Lab: Basic PE Check Off Review/Practice.

Pre-Class Prep: Review relevant text chapters.

Week 3, Feb 10:

Lecture: Dermatologic, HEENT

Lab: Interview, History & Documentation practice, basic PE check-offs

Pre-Class Prep: Review common lab/diagnostic tests and be prepared to discuss. Consider bringing a diagnostic testing (lab) reference to class, Practice basic physical exam

Week 4, Feb 17:

College of Nursing

Lecture: Chest (Breast, Respiratory & Cardiovascular) Clinic; Turn in Adult Screening History write-up (Drop Box)

Lab: Dermatologic, HEENT, Basic PE Checkoff

Pre-Class Prep: Review relevant text chapters. Case Study #1 Due.

Week 5, Feb 24:

Lecture: Musculoskeletal Assessment

Lab: Chest (Breast, Respiratory & Cardiovascular) Clinic

Pre-Class Prep: Review relevant text chapters.

Week 6, Mar 3:

Lab: Musculoskeletal Assessment

Lecture: Neurological Clinic; Focused Assessment Presentations

Pre-Class Prep: Review relevant text chapters.

Week 7, Mar 10:

Lab: Neurological Clinic

Lecture: GI Assessment

Pre-Class Prep: Review relevant text chapters.

Spring Break March 15-22, No Classes

Week 8, Mar 24:

Lab: GI Assessment

Lecture: GU/GYN, Reproductive Clinic

Pre-Class Prep: Review relevant text chapters. Case Study #2 Due.

Week 9, Mar 31:

Lab: GU/GYN, Reproductive Clinic

Lecture: Abdominal, GU/GYN, Reproductive Assessment & Documentation

Pre-Class Prep: Review relevant text chapters

Week 10, Apr 7:

College of Nursing

Lab: GU/GYN Assessment, Professional Models

Lecture: Mental Health Clinic

Pre-Class Prep: Review relevant text chapters, GU/GYN exam videos

Week 11, Apr 14:

Lab: GU/GYN Assessment, Professional Models

Due: Group Focused-Assessment Presentation and Reference materials posted on D2L Discussion area.

Lecture: Spiritual Health Assessment; Focused Assessment Presentations

Pre-Class Prep: Review relevant text chapters

Week 12, Apr 21:

Lab: Focused Assessment Practice

Lecture: Focused-Assessment Presentations

Pre-Class Prep: Review relevant text chapters

Week 13, Apr 28:

Lab: Focused-Assessment Check Offs

Lecture: Focused-Assessment Presentations

Pre-Class Prep: Review relevant text chapters

Week 14, May 5:

Lab: Focused-Assessment Check Offs, PE Kit Turn In

Lecture: Course Evaluations, Semester Wrap-Up

Pre-Class Prep: Material as needed

Shadow Healthcare DCE Assignment Time Estimates (Can be completed at any time during the semester).

College of Nursing

Assignment Approximate TimeDigital Clinical Experience™ (DCE) Orientation 10 - 15 minutes

Health History (Tina Jones) 75 minutes - 115 minutesHEENT (Tina Jones) 90 minutes - 145 minutes

Respiratory Concept Lab 25 minutesRespiratory (Tina Jones) 50 minutes - 125 minutes

Cardiovascular Concept Lab 25 minutesCardiovascular (Tina Jones) 45 minutes - 125 minutes

Abdominal Concept Lab 25 minutesAbdominal (Tina Jones) 35 minutes - 120 minutes

Musculoskeletal (Tina Jones) 50 minutes - 105 minutesNeurological (Tina Jones) 50  minutes - 105 minutesPsychological (Tina Jones) 30 minutes - 100 minutes

Clinical Decision Making (Tina Jones) 60 minutes

ACADEMIC CONDUCT

Students are expected to demonstrate academic integrity in all course activities. Academic integrity requires honesty concerning all aspects of academic work including:

Correct procedures for citing sources of information, words, and ideas Ways to properly credit collaborative work with project team or study group members Strategies for planning and preparing for examinations, papers, projects and presentations.

Students are encouraged to consult with faculty regarding any questions about appropriate behaviors to maintain academic integrity. Any violation of academic integrity will result in a zero on the assignment and may result in additional sanctions consistent with university policy

University Policies:

http://www.uwm.edu/Dept/SecU/SyllabusLinks.pdf

There are a few additional policies:

1. Inclement weather: UWM student should contact the University at 229-4444 (UW- Parkside, 262-595-2345) or check the appropriate website to ascertain the status of class cancellation due to inclement weather. Even when classes are canceled, University offices and services remain available, unless the entire University is closed by the Governor. http://www4.uwm.edu or http://www.uwp.edu

2. Safety: Safety techniques and strategies are described in College of Nursing Student Handbooks for undergraduate and graduate students distributed to all nursing students upon entering the program. Copies are available in the Office of Student Affairs. Information about UWM campus safety is found at http://www4.uwm.edu/current_students/student_services/safety.cfm

3. Technology and Social media: See student handbook

College of Nursing

4. Audio Recordings : Should you wish to audio record a lecture, it is a professional courtesy to request permission from the lecturer.

5. C ourse Time: This course consists of one 2 hour lecture and one 2 hour lab session per week. To prepare for this class time, the student should plan for at least 3-4 hours per class hour, for a total of approximately 16-18 hours per week.

College of Nursing

Lab Guide for

NURS 754

College of Nursing

Advanced History Taking

Upon completion of this unit the student will be able to:

Understand the components of a comprehensive health history and physical examination.

Discuss culturally competent approaches to taking a health history and performing a physical examination.

Identify how to assess a patient problem by proper application of symptom analysis and review of systems.

Define the components used in recording a comprehensive health history and physical examination.

Advanced Assessment of the Skin, Hair, and Nails

Advanced Assessment of the Head, Eyes, Ears Nose and Throat (HEENT)

Advanced Assessment of the Chest

Advanced Gastrointestinal Assessment

Advanced Assessment of the Musculoskeletal System

Advanced assessment of the Neurological System

Assessing Men’s and Women’s Genitourinary Health

The Focused Physical Final Examination

Upon completion of this course the student will be able to:

1. Correctly identify the components of a focused physical exam based on presenting history.2. Perform a focused physical examination of the adult using correct technique and sequence

for all systems examined.3. Determine a list of differential diagnoses consistent with presenting symptomology and

physical assessment findings.4. Identify appropriate diagnostic testing based on history, PE findings and list of differential

diagnoses.5. Accurately record a focused physical examination of the adult, including all key information

and using standard format.

College of Nursing

College of Nursing

Scoring Guides

for NURS 754

College of Nursing

UNIVERSITY OF WISCONSIN-MILWAUKEE COLLEGE OF NURSING

COMPREHENSIVE HEALTH ASSESSMENT SCORING GUIDE:

EVALUATION OF BASIC PHYSICAL EXAM

Student name: _____________________________________

Evaluator: _________________________________________

S=satisfactory /U=unsatisfactory

General Performance

1. Wash hands S U

2. Organize equipment & supplies S U

3. Maintain asepsis throughout exam S U

4. Maintain privacy and utilize appropriate draping S U

5. Maintain a safe environment S U

6. Uses an integrated exam sequence S U

Communication Skills

7. Responses to clients verbal and behavioral cues S U

8. Prepares client for process S U

9. Provides feedback to client regarding findings & plans S U

Skin

10. Inspect skin, hair, nails S U

11. Palpate for temperature, edema S U

College of Nursing

Head

12. Inspect and palpate head (include scalp, hair) S U

13. Inspect and palpate sinus areas S U

14. Palpate temporomandibular joint S U

15. Test CN V (motor and sensory) S U

16. Test CN VII (motor) S U

17. Auscultate and palpate temporal arteries S U

Eyes

18. Visual Acuity (Snellen, Rosenbaum, OS, OU, OD) S U

19. Assess alignment(corneal light reflex;cover/uncover test) S U

20. Assess for E.O.M.’s (CN III, IV, VI) S U

21. Test papillary responses (PERRLA) CN II, III S U

22. Inspect and palpate external structures S U

23. Perform ophthalmoscopic exam S U

Ears

24. Inspect and palpate external structures S U

25. Test gross hearing (watch or whisper test) S U

26. Perform otoscopic exam S U

Nose

27. Inspect and palpate external nose S U

28. Assess patency S U

29. Inspect internal structures S U

College of Nursing

Mouth

30. Inspect and palpate lips and oral cavity (gums, teeth,

Mucous membranes, sublingual area) S U

31. Inspect palates, tonsils S U

32. Test CN IX & X S U

33. Assess tongue (color, symmetry, strength (CN XII) S U

Neck

34. Inspect and palpate trachea S U

35. Palpate lymph nodes (preauricular, postauricular,

occipital, posterior and deep cervical, supraclavicular) S U

36. Assess CN XI (shoulder strength) S U

Respiratory (posterior, lateral and anterior)

37. Inspect thorax (P,L,A) S U

38. Palpate thorax systematically (P,L,A) S U

39. Auscultate lungs (P,L,A) S U

Cardiac

40. Auscultate and palpate carotids (bruits) S U

41. Inspect precordium sitting and supine S U

42. Palpate precordium sitting or supine S U

(5 areas and apical impulse)

College of Nursing

43. Auscultate heart sounds

(5 areas with bell and diaphragm) supine and sitting S U

44. Palpate pulses (brachial, radial, femoral, popliteal,

Posterior tibial & dorsalis pedis) S U

Abdomen

45. Inspect (2 positions of examiner) S U

46. Auscultate bowel sounds S U

47. Auscultate arteries for

Bruits (aorta; renal, iliac & femoral bilaterally) S U

48. Palpate inguinal nodes S U

49. Percussion systematically S U

50. Palpate systematically (light & deep) S U

51. Palpate liver S U

52. Assess CVA tenderness S U

Musculoskeletal

53. Assess head and neck and shoulder S U

(inspect, palpate, ROM, strength)

54. Assess elbows, wrists and hands S U

(inspect, palpate, ROM, strength)

55. Inspect and palpate spine S U

56. Assess spine (ROM, strength) S U

57. Assess hips and knees (inspect, palpate, ROM, strength) S U

College of Nursing

58. Assess ankles, feet and toes S U

(inspect, palpate, ROM, strength)

Neurological

59. Assess mental status S U

60. Assess sensory tactile sensation: S U

(stereognosis, graphesthesia)

61. Assess coordination of upper extremities S U

(Finger to nose, RAM) (pick 1)

62. Assess coordination of lower extremities S U

(heel to shin, RAM) (pick 1)

63. Assess gait S U

64. Heel to toe walking (Tandem walking) S U

65. Romberg S U

66. Assess deep tendon reflexes S U

(biceps, triceps, brachioradialis, patellar, Achilles)

Student score __________________

Student must successfully complete at least 83% of items (i.e. > 55/66 items) in 20 minutes or less to pass.

College of Nursing

University of Wisconsin-Milwaukee College of Nursing

NURS 754: Comprehensive Assessment of Health Implications for Clinical Decision Making

Scoring Guide: Case Study Documentation

Student Name___________________________________________________________

Item Criteria

History (3 points)1. “Elicited” an appropriate history using standard format. Requested appropriate additional information based on patient presentation

1..2..3..4..5

Physical Examination and Diagnostic Testing (3 points)

Indicate which components of the physical examination relevant to the patient’s presenting problem would be performed:

2. Appropriate exam chosen based on data provided 1..2..3..4..5

3. Appropriate diagnostic testing recommended 1..2..3..4..5…N/A

Proposed ASSESSMENT (3 points)4. Assessment and differential diagnoses appropriate given information provided. 1..2..3..4..5

5. Documentation thorough and concise. Appropriate SOAP format. 1..2..3..4..5

Proposed PLAN (1 point)6. Outline proposed general treatment plan, with BRIEF rationale. 1..2..3..4..5

5=no errors

4=1-3 errors

3=4-6 errors Raw score: _______/ # items

2=7-9 errors

1=> 10 errorsTotal Score: ___________/10

College of Nursing

University of Wisconsin-Milwaukee College of Nursing

Comprehensive Assessment of Health Implications for Clinical Decision Making

Focused Health & Aggregate Assessment Write-up

Directions

Students, working in groups, will be required to research and write up a common “focused” clinical problem based on the presenting symptoms of a case study patient. The chief complaint you and your colleagues will be working on will reflect those used for your practical final exam.

Each group will be given a chief complaint. Student groups should choose a diagnosis consistent with the chief complaint and develop a presentation that explores the “typical” presentation of a patient with that presenting symptom, including focused history, physical exam and diagnostic testing (if appropriate) findings. Also include a prioritized list of pertinent differential diagnoses.

Students may wish to include a chart or a paragraph or two that illustrates the major differences in your chosen diagnosis vs. the diagnoses on your list of differentials.

To further explore the health problem, groups will be asked to provide a brief review of the health problem, including incidence and prevalence and provide pertinent aggregate and environmental data, including the “typical” population affected by this problem and other epidemiological information. Please refer to the Scoring Guide: Focused Assessment Write-up when completing this project.

You should use several resources for this project, including course texts, Uphold & Graham, professional websites, journal articles, etc. Please upload bibliography, copy of your and presentation (in Powerpoint) to D2L discussion area at least 24 hours before the presentation day. Your presentation should be written up in Word or PowerPoint format and uploaded to the discussion area on D2L at least two weeks prior to the scheduled presentation date.

Please feel free to use D2L discussion board and email to discuss these cases. I will answer any questions you may have via email or in class. Have fun!

College of Nursing

University of Wisconsin-Milwaukee College of Nursing

NURS 754: Comprehensive Assessment of Health Implications for Clinical Decision Making

Scoring Guide: Focused Health & Aggregate Assessment Presentation

Student Names___________________________________________________________

Topic: __________________________________________________________________

Item Criteria

Individual assessment

1. Appropriate historical data included/recommended to elicit based on chief complaint

Yes......No

Appropriate physical examination and diagnostic testing (if appropriate) recommended based on chief complaint and historical data

2. Avoided selecting too many/few examination components.Yes......No

3. Appropriate diagnostic testing ordered or performed Yes...No…N/A

4. Prioritized differential diagnoses appropriate given data collected.Yes......No

Aggregate assessment

5. Clear and comprehensive description of the aggregate generally affected by this health problem

Yes......No

6. Presentation of data as it relates to the problem, the population. Include incidence/prevalence

Yes......No

7. Evaluated environmental issues potentially related to this health problem

Yes......No

College of Nursing

Professional Criteria

8. Identification of implications, constraints and facilitating factors for decision making for the APN/in the clinical setting

Yes......No

9. Appropriateness of data sources Yes......No

10. Professional presentation Yes......No

Comments: Score: /25

College of Nursing

University of Wisconsin-Milwaukee College of Nursing

NURS 754: Comprehensive Assessment of Health Implications for Clinical Decision Making

Scoring Guide: Focused Assessment Final Examination

Student Name:____________________________________________________

Evaluator:____________________

Item Criteria1. Elicited appropriate history. Requested appropriate additional information based on patient presentation

/4

2. Selected appropriate physical examination based on CC & Hx /4

3. Accurately performed physical examination components./4

4. Appropriate diagnostic testing selected based on H&P findings/4

5. Selected correct diagnosis:/3

6. Prioritized list of differential diagnoses is appropriate given information provided.

/2

7. Prioritized list of proposed treatment plan /2

Professional Criteria7. Encounter conducted in an efficient yet caring manner, including nurse’s

ability to relate to patient’s age, developmental stage, educational level, mental status, and demeanor. /4

8. Assessment completed within 20 minutes /3

Comments:

Final Score: /30