Students rated as “proficient” demonstrate an entry-level expertis
of a proficient practitioner.
Digital Clinical Experience Score
100%
Subjective Data Collection Objective Data Collection
18 out of 18 28 out of 28
This score measures your performance on the Student Performance Index in relation to and
Education otherEmpathy
students in comparable academic programs. Yo
4 out of 4
Time
84 minutes total spent in assignment
Interaction with patient
84 minutes
Comments
If your instructor provides individual feedback on this assignment, it will appear here.
Musculoskeletal Results | Turned In
Nursing 562/562L Advanced Health Assessment - Spring 2021, N562
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Overview
Subjective Data Collection: 18 of 18 (100.0%)
Transcript
Subjective Data
Hover To Reveal... Indicates an item that
Collection Objective Data you found.
Hover over the Patient Data Indicates an item that
Collection Education & items below to reveal important is available to be found.
information, including Pro Tips
Empathy Documentation and Example Questions.
Category Scored Items Patient Data
Not Scored
Experts selected these topics as essential components
A combination of open and closed questions will
of a strong, thorough interview with this patient.
yiel better patient data. The following details are
facts of patient's case.
Chief Complaint
Established chief complaint Reports low back pain
Describes injury as a "tweak" to her back
History of Present Illness
Asked about onset of pain Reports original injury occurred 3 days ago
Onset was sudden
Reports injury happened when lifting a heavy box
Asked about location of pain Reports pain located in low back and buttocks
Reports pain does not radiate or migrate
Denies neck pain
Denies pain between the shoulder blades
Reports pain is the same on both sides of her
back
Asked about frequency and duration of pain Reports pain has lasted three days
Reports pain is constant
, 3/16/20 Musculoskeletal | Completed | Shadow
Asked about severity of pain Describes current pain as "pretty bad"
Rates pain of original injury as 6 or
7/10 Reports current pain rating of
5/10
Asked about character of pain Reports pain at the onset as sharp
Describes pain as aching
Denies burning pain
Reports back is sore to the touch
Reports pain accompanied by stiffness
Asked about aggravating factors Reports feeling least comfortable when
sitting Reports some pain with movement
such as
bending or walking
Asked about relieving factors Reports slight pain relief with rest
Reports feeling most comfortable when lying
flat on back
Denies use of heating pad or ice
Asked about impact of pain on activities of
Confirms pain is interfering with activities of daily
daily living living
Reports slight sleep disturbance due to the pain
Reports no exercise since accident
Reports receiving help with daily tasks
from mother and sister
Medical History
Confirmed use of medications Confirms medications
Reports increased ibuprofen use for pain
Followed up on ibuprofen use Has taken ibuprofen for the past 3 days
Last dose of ibuprofen was about 5 hours ago
Reports taking two Ibuprofens at a time
Takes ibuprofen every 5-6 hours as per
instructions
Unsure of dose, describes it as "not extra
strength"
Ibuprofen provides relief for several hours
Confirmed allergies Confirms allergies (no new allergies reported)
Asked about possible contributing factors in
Reports no history of previous back pain or
health history injury Denies history of severe trauma such as
car
accident or occupational injury
Denies past surgery
Denies increase in alcohol use since
injury Denies history of fractures
Denies heavy lifting at work
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