NR509 Neurological Documentation Shadow

NR509 Neurological Documentation Shadow

Document: Provider Notes

 Student Documentation

Subjective

HPI: Tina Jones comes to the clinic with the chief complaint of headaches and neck stiffness. This occured about five days ago, but the patient was in a minor “fender bender” a week ago. Tina was the passenger and she was wearing a seatbelt. She claims that the accident was at low speed. She did not seek further care after the EMTs looked her over and declared that she was okay. However, two days later, she started to have terrible headaches ad her stiff neck. She also notes that her neck may be swollen. Tina did not lose conciousness, not has she lost conciousness or fainted since. She has been having a headaches daily for the last five days. The headaches last “about an hour or two” and she rates the severity at a 4. She describes the pain as “a dull ache in the corwn of my head and the back of my head.” She takes Tylenol to manage the pain as needed. She did not know the dose, but she “generally takes 2 regular strength pills.” She denies any other symptoms.

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Social History: Patient states that she always wears her seat belt. She claims that she is a safe driver. Her father was in an accident, so she takes it seriously. Patient does not smoke or do drugs.

denies any trauma before the car accident. Eyes: Patient does not wear corrective lenses.

Patient states that her vision becomes blurry when she reads for extended periods. States that her vision is worsening. Patient denies eye pain or itching.

Ear: patient denies any ear pain or ringing in the ears.

Nose: Patient denies any congestion and sneezing. Patient does not an allergy to cats and mold that can cause sneezes.

Musculoskeletal: Patient denies any muscle pain or weakness anywhere other than her neck. Patient notes possible swelling in the neck, but nowhere else.

Neurologic: Patient denies any weakness or dizziness. Patient denies fainting. Patient denies any tingling or tremors. Patient notes no changes in bladder or bowels. Patient denies any changes in concentration or sleep.

Objective

General: Ms. Jones is a pleasant and agreeable 28 year old african american female. She is dressed nicely and answers questions during the exam fully. She stayed alert the entire time.

Mental Status: confirmed orientation to person, to place, and to time. Patient could succesfully think abstractly and relevantly. Tested the patient’s attention span with a serial 7 test and she completed it accurately. Patient’s comprehension was evaluated and she was able to follow instructions. Patient could accurately answer general knowledge questions.

Patient’s judgement is intact. Patient’s remote memory, imemdiate memory, and new learning ability are intact and accurate. Patient’s observed vocabulary was to be expected for the patient’s age and ability, and there were no problems with her articulation or pronunciation.

Cranial Nerves: Olfactory nerve intact as patient could discriminate smell and it was also symemetric bilaterally. Visual acutiy: right eye 20/40, left eye 20/20. Fundoscopic exam reveled sharp right disc margin with cotton wool bodies. Left eye had sharp disc margin with no abnormal findings. Observed pupils with penlight: PEERL. Extraocular eye movements: cardinal fields and convergence revealed no abnormal findings. Facial sensations to dull, soft, and sharp were intact. Skull and facial features were symmetric. Weber test was normal. Rinne test normal on both sides. Gag reflex intact. Accesory nerve in the shoulders and neck were tested against resistance with a grade of 5 meaning full range of motion. Tongue was symmetric with no abnormal findings.

ROS:

General: patient denies any fatigue or weakness. Head: patient denies any current headache. patient

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Model Documentation

HPI: Ms. Jones presents to the clinic complaining of a headache and neck stiffness that started 2 days after she was in a minor fender bender. One week ago she states that she was a restrained passenger in an accident in a parking lot and estimates the speed to be approximately 5-10 mph. She and the driver did not seek emergent care and felt fine after the accident. Two days later, however, she developed a bilateral temporal dull ache accompanied by neck ache. She states that she feels as though her neck may be slightly swollen as well. She did not lose consciousness in the accident and denies changes in level of consciousness since that time. She states that she gets a headache every day that lasts approximately 1-2 hours. She occasionally takes 650 mg of over the counter Tylenol with relief of the pain. She denies known associated symptoms.

Review of Systems: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. • Head: Denies history of trauma before this incident. Denies current headache. • Eyes: She does not wear corrective lenses, but notes that her vision has been worsening over the past few years, but no acute changes. She complains of blurry vision after reading for extended periods. Denies increased tearing or itching. • Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache. • Nose/Sinuses: Denies rhinorrhea. Denies stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure. • Musculoskeletal: Denies muscle weakness, pain, difficulties with range of motion, joint

instability, or swelling. • Neurologic: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures. Denies bowel or bladder dysfunction. Denies changes in concentration, sleep, coordination, appetite.

Objective

General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress, but appears uncomfortable while sitting in exam chair. She is alert and oriented. She maintains eye contact throughout interview and examination.

  • Head: Head is normocephalic and atraumatic
  • Eyes: Bilateral eyes with equal hair
  • Neurologic: Sense of smell intact and symmetric. Left eye vision: 20/20. Right eye vision: 20/40. Left fundoscopic exam reveals sharp disc margins, no hemorrhages. Right fundoscopic exam reveals mild retinopathic changes. Pupils equal, round, and reactive to light bilaterally. Extraocular movements intact bilaterally. Normal convergence. Facial sensation intact; facial features and symmetric. Rinne and Weber tests normal Gag reflex intact. Ability to shrug shoulders symmetric; 5 strength against resistance. Neck with full range of motion against resistance; 5 strength against resistance. Tongue symmetric with no abnormal findings. Bilateral upper and lower extremity DTRs equal and 2+ bilaterally. Point-to-point movements smooth and accurate for finger-to-nose and heel-to- shin. Rapid alternating movements of the upper extremities intact bilaterally. Gait steady with continuous, symmetric steps. Sensation intact to bilateral upper and lower extremities; sense of extremity position intact. Stereognosis and graphesthesia intact bilaterally.

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Shadow Health Physical Assessment Rubric

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Shadow Health Physical Assessment Rubric
CriteriaRatingsPts
Edit criterion descriptionDelete criterion rowThis criterion is linked to a Learning OutcomeSubjective Data, Organization, Communication, and Summary (DCE Score or transcript) _9172view longer descriptionRangethreshold: ptsEdit ratingDelete rating25.0 to >21.0 ptsAbove Average- DCE Score greater than or equal to 93; Comprehensive introduction with expectations of exam verbalized; questions worded in a non-judgmental way; professional language exercised; questions well-organized; appropriate closing with summary of findings verbalized to patient._7235Edit ratingDelete rating21.0 to >10.0 ptsAverage- DCE Score greater than or equal to 86-92; Adequate introduction; some questions worded in a non-judgmental way; professional language mostly exercised; questions generally organized; somewhat complete closing._9258Edit ratingDelete rating10.0 to >0.0 ptsBelow Average- DCE Score greater than or equal to 80-85; Incomplete introduction; many questions worded in a judgmental way; some professional language exercised; questions somewhat organized; incomplete closing._2206Edit ratingDelete rating0.0 to >0 ptsUnsatisfactory- DCE Score less than or equal to 79; Introduction missing; questions worded in a judgmental way; little professional language; questions unorganized; closing missing._4625This area will be used by the assessor to leave comments related to this criterion.pts/ 25.0 pts—
Edit criterion descriptionDelete criterion rowThis criterion is linked to a Learning OutcomeObjective Data, Physical Examination, Interpretation of Findings, Assessment, and Documentation _5446view longer descriptionRangethreshold: ptsEdit ratingDelete rating20.0 to >16.0 ptsAbove Average- Physical assessment documentation includes all relevant body systems; all pertinent normal and abnormal findings identified; documentation reflects professional language; treatment plan includes each of the following components: diagnostics, medication, education, consultation/referral, and follow-up planning._8504Edit ratingDelete rating16.0 to >8.0 ptsAverage- Physical assessment documentation lacks sufficient details pertaining to one or two relevant body systems; or identifies ≥ 50% of the pertinent normal and abnormal findings; or documentation lacks professional language; or treatment plan lacks one or two components (diagnostics, medication, education, consultation/referral, or follow-up planning)._9311Edit ratingDelete rating8.0 to >0.0 ptsBelow Average- Physical assessment documentation lacks sufficient details pertaining to three or more relevant body systems; or identifies < 49% of the pertinent normal and abnormal findings; or documentation includes unprofessional language; or treatment plan lacks three or more components (diagnostics, medication, education, consultation/referral, or follow-up planning)._1424Edit ratingDelete rating0.0 to >0 ptsUnsatisfactory- No physical assessment documentation or no treatment plan._224This area will be used by the assessor to leave comments related to this criterion.pts/ 20.0 pts—
Edit criterion descriptionDelete criterion rowThis criterion is linked to a Learning OutcomeSelf-Reflection _3128view longer descriptionRangethreshold: ptsEdit ratingDelete rating5.0 to >3.0 ptsAbove Average- Responds to three of the three reflection post questions; and provides analysis of performance; and reflection posts written using professional language; and reflection posts demonstrate insight._7104Edit ratingDelete rating3.0 to >2.0 ptsAverage- Responds to two of the three reflection post questions; or provides limited self-analysis of performance; or reflection posts are somewhat unclear related to the assignment and the student’s experience; or reflection posts lack insight._9169Edit ratingDelete rating2.0 to >0.0 ptsBelow Average- Responds to one of the three reflection post questions; or does not provide self-analysis of performance; or reflections are not related to the assignment and the student’s experience; or does not provide insight_2706Edit ratingDelete rating0.0 to >0 ptsUnsatisfactory- No reflection posts for the assignment._6746This area will be used by the assessor to leave comments related to this criterion.pts/ 5.0 pts—
Edit criterion descriptionDelete criterion rowThis criterion is linked to a Learning OutcomeDescription of criterionview longer descriptionRangethreshold: 5 ptsEdit ratingDelete rating5to >0 ptsFull MarksblankEdit ratingDelete rating0to >0 ptsNo Marksblank_2This area will be used by the assessor to leave comments related to this criterion.pts/ 5 pts—
Total Points: 50.0 out of 50.0
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Title

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Title
CriteriaRatingsPts
Edit criterion descriptionDelete criterion rowThis criterion is linked to a Learning OutcomeDescription of criterionview longer descriptionRangethreshold: 5 ptsEdit ratingDelete rating5to >0 ptsFull MarksblankEdit ratingDelete rating0to >0 ptsNo Marksblank_2This area will be used by the assessor to leave comments related to this criterion.pts/ 5 pts—
Edit criterion descriptionDelete criterion rowThis criterion is linked to a Learning OutcomeDescription of criterionview longer descriptionRangethreshold: 5 ptsEdit ratingDelete rating5to >0 ptsFull MarksblankEdit ratingDelete rating0to >0 ptsNo Marksblank_2This area will be used by the assessor to leave comments related to this criterion.pts/ 5 pts—
Total Points: 5 out of 5
Top of FormI’ll write free-form comments when assessing studentsRemove points from rubricDon’t post Outcomes results to Learning Mastery GradebookUse this rubric for assignment gradingHide score total for assessment resultsCancelCreate RubricBottom of Form