Assignment 2: Digital Clinical Experience (DCE): Health History Assessment

Assignment 2: Digital Clinical Experience (DCE): Health History Assessment

Assignment 2: Digital Clinical Experience (DCE): Health History Assessment

Assignment 2: Digital Clinical Experience
(DCE): Health History Assessment
A comprehensive health history is essential to providing quality care for patients across
the lifespan, as it helps to properly identify health risks, diagnose patients, and develop
individualized treatment plans. To effectively collect these heath histories, you must not
only have strong communication skills, but also the ability to quickly establish trust and
confidence with your patients. For this DCE Assignment, you begin building your
communication and assessment skills as you collect a health history from a volunteer
"patient."

Photo Credit: Sam Edwards / Caiaimage / Getty Images

To Prepare

 Review this week’s Learning Resources as well as the Taking a Health History media
program, and consider how you might incorporate these strategies. Download and review
the Student Checklist: Health History Guide and the History Subjective Data Checklist,
provided in this week's Learning Resources, to guide you through the necessary
components of the assessment.
 Access and login to Shadow Health using the link in the left-hand navigation of the
Blackboard classroom.
 Review the Shadow Health Student Orientation media program and the Useful Tips and
Tricks document provided in the week’s Learning Resources to guide you through
Shadow Health.
 Review the Week 4 DCE Health History Assessment Rubric, provided in the Assignment
submission area, for details on completing the Assignment.
DCE Health History Assessment:
Complete the following in Shadow Health:
Orientation (Required, you will not be able to access the Health History without completing
the requirements).
 DCE Orientation (15 minutes)
 Conversation Concept Lab (50 minutes)
Health History
 Health History of Tina Jones (180 minutes)
Note: Each Shadow Health Assessment may be attempted and reopened as many times as
necessary prior to the due date to achieve total score of 80% or better(includes BOTH DCE and
Documentation), but you must take all attempts by the Week 4 Day 7 deadline.
Submission and Grading Information
No Assignment submission due this week but will be due Day 7, Week 4.
Grading Criteria

To access your rubric:
Week 4 Assignment 2 DCE Rubric

Learning Resources

Required Readings (click to expand/reduce)

Note: To access this week's required library resources, please click on the link to
the Course Readings List, found in the Course Materials section of your Syllabus.
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 3, “Examination Techniques and Equipment”
This chapter explains the physical examination techniques of inspection,
palpation, percussion, and auscultation. This chapter also explores special issues
and equipment relevant to the physical exam process.

 Chapter 8, “Growth and Nutrition”
In this chapter, the authors explain examinations for growth, gestational age, and
pubertal development. The authors also differentiate growth among the organ
systems.

 Chapter 5, “Recording Information”  (Previously read in Week 1)
This chapter provides rationale and methods for maintaining clear and accurate
records. The text also explores the legal aspects of patient records.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019).
Student checklist: Health history guide. In Seidel's guide to physical examination
(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.

Centers for Disease Control and Prevention. (2018). Childhood overweight
and obesity. Retrieved from http://www.cdc.gov/obesity/childhood

This website provides information about overweight and obese children.
Additionally, the website provides basic facts about obesity and strategies
to counteracting obesity.

Chaudhry, M. A. I., & Nisar, A. (2017). Escalating health care cost due to
unnecessary diagnostic testing. Mehran University Research Journal of
Engineering and Technology, (3), 569.

This study explores the escalating healthcare cost due the
unnecessary use of diagnostic testing. Consider the impact of health
insurance coverage in each state and how nursing professionals must
be cognizant when ordering diagnostics for different individuals.

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 1, “Clinical Reasoning, Evidence-Based Practice, and Symptom
Analysis”

This chapter introduces the diagnostic process, which includes performing an
analysis of the symptoms and then formulating and testing a hypothesis. The
authors discuss how becoming an expert clinician takes time and practice in
developing clinical judgment.

Gibbs , H., & Chapman-Novakofski, K. (2012). Exploring nutrition literacy:
Attention to assessment and the skills clients need. Health, 4(3), 120–124.

This study explores nutrition literacy. The authors examine the level
of attention paid to health literacy among nutrition professionals and
the skills and knowledge needed to understand nutrition education.

Martin, B. C., Dalton, W. T., Williams, S. L., Slawson, D. L., Dunn, M. S., &
Johns-Wommack, R. (2014). Weight status misperception as related to selected
health risk behaviors among middle school students. Journal of School Health,
84(2), 116–123. doi:10.1111/josh.12128
Credit Line: Weight status misperception as related to selected health risk
behaviors among middle school students by Martin, B. C., Dalton, W. T.,
Williams, S. L., Slawson, D. L., Dunn, M. S., & Johns-Wommack, R., in Journal
of School Health, Vol. 84/Issue 2. Copyright 2014 by Blackwell Publishing.
Reprinted by permission of Blackwell Publishing via the Copyright Clearance
Center.

Noble, H., & Smith, J. (2015) Issues of validity and reliability in qualitative
research . Evidence Based Nursing, 18(2), pp. 34–35.

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R.
W. (2011). History subjective data checklist. In Mosby’s guide to physical
examination (7th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Mosby’s Guide to Physical Examination, 7th Edition by Seidel, H.
M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R.
W. Copyright 2011 by Elsevier. Reprinted by permission of Elsevier via the
Copyright Clearance Center.

This History Subjective Data Checklist was published as a companion to Seidel’s
Guide to Physical Examination (8th ed.) by Ball, J. W., Dains, J. E., & Flynn, J.A.
Copyright Elsevier (2015). From https://evolve.elsevier.com

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 Week 1)
 Chapter 5, "Pediatric Preventative Care Visits" (pp. 91 101)
Shadow Health Support and Orientation Resources
Use the following resources to guide you through your Shadow Health orientation as well
as other support resources:

Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file].
Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY

Document: Shadow Health Support and Orientation Resources (PDF)

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: Shadow Health Nursing Documentation Tutorial (Word document)

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.

Optional Resource
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic
examination (10th ed.). New York, NY: McGraw Hill Medical.

 Chapter 3, "The Physical Screening Examination"
 Chapter 17, "Principles of Diagnostic Testing"
 Chapter 18, "Common Laboratory Tests"

Required Media (click to expand/reduce)

Taking a Health History

How do nurses gather information and assess a patient’s health? Consider the
importance of conducting an in-depth health assessment interview and the

strategies you might use as you watch. (16m)

Assessment Tool, Diagnostics, Growth, Measurements, and Nutrition in Adults and

Children – Week 3 (11m)