Part I: Comprehensive Health History (Subjective Data Only)
The health history includes only information reported by the patient.
Be sure to:
· Expand the HPI using OLDCARTS
· Write the HPI as a cohesive paragraph (not bullet points)
· Include complete:
· Past Medical History (PMH)
· Past Surgical History (PSH)
· Medications
· Allergies
· Family History
· Preventive Health
· Social History
· Social Determinants of Health (SDOH)
· Complete a focused Review of Systems (ROS)
Tip: If specific information is not provided in the case study, you may create reasonable subjective findings and history details to complete the assessment. The goal is complete and professional documentation.
Part II: Focused Physical Examination (Objective Data Only)
The physical examination includes only what the clinician observes, palpates, percusses, or auscultates.
Be sure to:
· Perform and document a focused exam appropriate to the chief complaint
· Document expected objective findings based on your clinical reasoning
· Use professional medical terminology
· Maintain logical organization
· Align the examination with the patient’s presenting complaint
Do NOT Include
This assignment evaluates assessment and documentation skills only.
Do not include:
· Diagnosis
· Differential diagnoses
· Treatment plan
· Prescriptions
· Patient education
Documentation Tips
One of the biggest opportunities for success on this assignment is clearly separating subjective and objective findings.
Subjective = What the Patient Reports
Examples include:
· Symptoms
· Health history
· Symptoms the patient admits or denies during the ROS
· Patient concerns
Objective = What the Clinician Finds
Examples include:
· Inspection findings
· Palpation findings
· Percussion findings
· Auscultation findings
A helpful question to ask yourself:
“Did the patient tell me this, or did I observe it?”
If the patient reported it, it belongs in the history. If you observed it, it belongs in the physical exam.
Evidence-Based Practice Requirement
You must include a minimum of three scholarly references published within the last five years.
References should support:
· Clinical assessment of integumentary complaints
· Focused skin examination principles
· Reflection content
Acceptable sources include:
· Peer-reviewed journal articles
· CDC clinical guidance
· IDSA guidelines
· Advanced practice nursing scholarly texts
· WHO clinical documents
Please ensure all references and citations are formatted according to APA guidelines.
Part III: Reflection
After completing your documentation, complete the reflection section included in the assignment template.
This is your opportunity to reflect on:
· Separating subjective and objective findings
· Integumentary assessment skills
· Clinical reasoning and documentation development
Before You Submit
Be sure to review:
· Learning Resources from Weeks 1–4
· Comprehensive Health History Reference Sheet
· Physical Exam Reference Sheet
· Simulation Case Study #2: Painful Rash
· Current evidence-based guidelines related to the patient’s complaint
· Assignment Template
· Assignment Rubric
The rubric is your roadmap to success—use it as a checklist before submitting your work.
REQUIRED SOURCES:
NOTE: Utilize this text as a clinical reference to aid your analysis for the relevant areas noted. Also utilize study questions to develop your understanding of the concepts and topics presented throughout this course.
· Soriano, R. P. (2026). Bates’ guide to physical examination and history taking(14th ed.). Wolters Kluwer Health.
· Chapter 13, “Head and Neck”
· Chapter 14, “Eyes”
· Chapter 15, “Ears and Nose”
· Chapter 16, “Throat and Oral Cavity”
· American College of Radiology. (n.d.). Appropriateness Criteria Links to an external site. . https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria
· Document: Comprehensive Health History Reference Sheet (PDF) Download Comprehensive Health History Reference Sheet (PDF)
· Document: Physical Exam Reference Sheet (PDF) Download Physical Exam Reference Sheet (PDF)
· Document: Week 4 Assignment Template (Word) Download Week 4 Assignment Template (Word)
· Walden University, LLC. (n.d.). Simulation case study #2: Painful rashLinks to an external site. . Walden University Canvas. https://waldenu.instructure.com
INSTRUCTIONS:
· Review Learning Resources in Weeks 1–4.
· Download and review the “ Comprehensive Health History Reference Sheet Download Comprehensive Health History Reference Sheet” and the “ Physical Exam Reference Sheet Download Physical Exam Reference Sheet.”
· Access Simulation Case Study #2: Painful RashLinks to an external site. .
· Review current evidence-based guidelines related to the patient complaint.
· Download the Assignment Template Download Download the Assignment Template.
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)
Part II: Focused Physical Examination (Objective Data 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.
Part III: Reflection (1–2 pages)
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.
RUBRIC:
NURS_6512_Module2_Assignment_Rubric