Based on the case, complete document a comprehensive health history (subjective data only) and a focused physical examination (objective data only).  Do NOT provide:  A diagnosis  A differential diagnosis list

The Assignment 

Based on the case, complete document a comprehensive health history (subjective data only) and a focused physical examination (objective data only). 

Do NOT provide: 

  • A diagnosis 
  • A differential diagnosis list 
  • A treatment plan 
  • Prescriptions 
  • Patient education 

This assignment evaluates assessment and documentation skills only. 

Expand the health history and focused physical examination results as appropriate by identifying and documenting expected findings. You may include your own version of history sections as you see fit. In other words, you can formulate your own health history and objective data of the patient as long as it is properly documented. 

Part I: Comprehensive Health History (Subjective Data Only)

Reminder: The health history includes only information provided by the patient. It should not include physical exam findings. 

You must: 

  • Expand the HPI using OLDCARTS 
  • Write the HPI as a cohesive paragraph (not bullet points) 
  • Include complete PMH, PSH, medications, allergies, preventive health, social history, and SDOH 
  • Complete a comprehensive or focused ROS (subjective only) 

Reminder: The physical exam includes only what the clinician observes, palpates, percusses, or auscultates. 

You must: 

  • Perform and document a focused examination appropriate to the chief complaint, 
  • Determine and document what objective findings you would expect to assess and record based on your clinical reasoning. 

Documentation Expectations 

You must: 

  • Clearly separate subjective and objective data 
  • Avoid including patient-reported symptoms in the physical exam section 
  • Avoid including exam findings in the history section 
  • Use professional medical terminology 
  • Demonstrate logical organization 
  • Align examination scope with the chief complaint 

Evidence-Based Practice Requirement 

Your documentation must incorporate a minimum of three, evidence-based scholarly references published within the last five years (≤ 5 years old). Cite all sources in APA format.  

References must support: 

  • Clinical assessment of integumentary complaints 
  • Focused skin examination principles 
  • Any portion of the reflection section 

Acceptable Sources: 

  • Peer-reviewed journal articles 
  • CDC clinical guidance 
  • IDSA guidelines 
  • Advanced practice nursing scholarly texts 
  • WHO clinical documents 

Unacceptable Sources: 

  • Patient education websites (e.g., Mayo Clinic, Cleveland Clinic, WebMD, Healthline) 
  • Wikipedia 
  • Blogs or commercial health sites 

All references must be cited in APA format. 

After completing your comprehensive health history and focused physical examination, submit a reflection addressing the reflection prompts in the assignment template. This reflection is designed to help you strengthen your ability to clearly separate subjective and objective findings while performing an integumentary assessment. NURS_6512_Module2_Assignment_Rubric

NURS_6512_Module2_Assignment_Rubric

Criteria

Ratings

Pts

This criterion is linked to a Learning OutcomePart I:
Comprehensive Health History (Subjective Data Only)… Demonstrates accurate
and complete documentation of patient comprehensive health history
(subjective data only).

25 to >22.35 ptsExcellentProvides accurate
and complete documentation of patient comprehensive health history
(subjective data only).

22.35 to >19.85 ptsGoodProvides a
mostly accurate and complete patient comprehensive health history (subjective
data only); may contain some minor errors.

19.85 to >0 ptsPoorDoes not provide
documentation of patient health history (subjective data only); documentation
is inaccurate and/or incomplete.

25 pts

This criterion is linked to a Learning OutcomePart II:
Focused Physical Examination (Objective Data Only)… Demonstrates accurate
and complete documentation of patient focused physical examination (objective
data only).

25 to >22.35 ptsExcellentProvides
accurate and complete documentation of patient focused physical examination
(objective data only).

22.35 to >19.85 ptsGoodProvides a
complete, mostly accurate documentation of patient focused physical
examination (objective data only); may contain some minor errors.

19.85 to >0 ptsPoorDoes not provide
documentation of patient focused physical examination (objective data only);
data provided is inaccurate and/or incomplete.

25 pts

This criterion is linked to a Learning OutcomePart III:
Reflection Section 1: Subjective vs. Objective Distinction…Identify two
examples where it may have been challenging to separate subjective from
objective data; Explain how you ensured that patient-reported symptoms
remained in the history section; Explain how you ensured that only observable
or measurable findings were included in the physical exam section.

15 to >13.41 ptsExcellentProvides two
fully developed examples of situations that posed a challenge separating
subjective and objective data… Fully explains how they ensured that
patient-reported symptoms remained in the history section… Fully explains
how they ensured that only observable or measurable findings were included in
the physical exam section.

13.41 to >11.91 ptsGoodProvides two
adequately developed examples of situations that posed a challenge separating
subjective and objective data… Adequately explains how they ensured that
patient-reported symptoms remained in the history section… Adequately
explains how they ensured that only observable or measurable findings were
included in the physical exam section.

11.91 to >0 ptsPoorDoes not provide
examples of situations that posed a challenge separating subjective and
objective data; explanations are unclear or incomplete.

15 pts

This criterion is linked to a Learning OutcomePart III:
Reflection Section 2: Additional Assessment Questions… Identify 2–3
additional questions you would ask to strengthen your subjective
assessment…. For each question: State the question; Briefly explain why it
is important; Describe how the response could guide your focused physical
examination

10 to >8.94 ptsExcellentIdentifies 2–3
additional questions they would ask to strengthen their subjective
assessment… Provides a fully developed explanation of why the question is
important… Provides a fully developed description of how the response could
guide their focused examination.

8.94 to >7.94 ptsGoodIdentifies 2–3
additional questions they would ask to strengthen their subjective
assessment… Provides an adequately developed explanation of why the
question is important… Provides an adequately developed description of how
the response could guide their focused examination.

7.94 to >0 ptsPoorDoes not identify
2–3 additional questions they would ask to strengthen their subjective
assessment; the questions provided are unclear, inaccurate, or incomplete.

10 pts

This criterion is linked to a Learning OutcomePart III:
Reflection… Section 3: Professional Growth… Identify one area of your
assessment skills that you would like to improve (e.g., documenting vesicular
lesions, describing rash morphology, lymph node assessment). Briefly explain
how you plan to strengthen that skill.

10 to >8.94 ptsExcellentIdentifies one
area of their assessment skills they would like to improve… Provides a
fully developed explanations of how they plan to strengthen that skill.

8.94 to >7.94 ptsGoodIdentifies one
area of their assessment skills they would like to improve… Provides an
adequately developed explanations of how they plan to strengthen that skill.

7.94 to >0 ptsPoorDoes not identify
one area of assessment skills they would like to improve; explanation is
unclear, inaccurate, or incomplete.

10 pts

This criterion is linked to a Learning OutcomeUses at
least 3 scholarly resources that are less than 5 years old.

5 to >4.46 ptsExcellentUses 3
peer-reviewed scholarly sources published within the last 5 years.

4.46 to >3.96 ptsGoodUses 2
peer-reviewed scholarly sources published within the last 5 years.

3.96 to >3.46 ptsFairUses 1
peer-reviewed scholarly source published within the last 5 years.

3.46 to >0 ptsPoorDoes not use
peer-reviewed scholarly sources or sources used are older than 5 years.

5 pts

This criterion is linked to a Learning OutcomeSource
Attribution and APA Formatting

5 to >4.46 ptsExcellentAll sources are
cited in APA format without any errors.

4.46 to >3.96 ptsGoodAll sources are
cited in APA format with some minor errors.

3.96 to >3.46 ptsFairAll sources are
cited with frequent APA formatting errors.

3.46 to >0 ptsPoorMissing source
citations and/or minimal adherence to APA formatting rules.

5 pts

This criterion is linked to a Learning OutcomeGrammar,
Mechanics, and Punctuation

5 to >4.46 ptsExcellentCorrect
grammar, spelling, and punctuation with no errors.

4.46 to >3.96 ptsGoodCorrect grammar,
spelling, and punctuation with few errors.

3.96 to >3.46 ptsFairCorrect grammar,
spelling, and punctuation with frequent errors.

3.46 to >0 ptsPoorFrequent
errors in grammar, spelling, and punctuation that interfere with
comprehension.

5 pts

Total Points: 100

Recent Comments

No comments to show.