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Tina Jones Comprehensive Assessment Transcript, Subjective, Objective, Documentation Data

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Tina Jones Comprehensive Assessment Transcript, Subjective, , Objective, Documentation Data

Institution
Physical Assessment In Healthcare
Module
Physical Assessment in Healthcare











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Institution
Physical Assessment in Healthcare
Module
Physical Assessment in Healthcare

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Uploaded on
October 16, 2024
Number of pages
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Written in
2024/2025
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10/16/24, 11:44 Tina Jones Comprehensive Assessment Transcript, Subjective,
AM Objective…




Tina Jones Comprehensive Assessment
Transcript

Started: Nov 22, 2022 | Total Time: 212 min

Your Avatar. Hello! Question

11/11/24 10:23 AM EST

Character avatar. Hi. Im Preceptor Diana. I will explain the details of this assignment and your
objectives, just as a preceptor would in real life. Pay close attention to this information as it will help
guide your exam. At the end of this prebrief, you will answer a short question about the upcoming
assignment. During the simulation, you may return to these instructions at any time by scrolling to the
top of your transcript.

Your Avatar. What is the situation? Question

11/11/24 10:23 AM EST

Character avatar. Six months have passed since Tina Jones was admitted to Shadow General
Hospital, and her foot wound has healed. Your role in this simulation is that of a healthcare provider
who will perform a comprehensive assessment on Ms. Jones to demonstrate your clinical
competency.

Your Avatar. What are my objectives in this assessment? Question

11/11/24 10:24 AM EST

Character avatar. You will collect subjective data from Ms. Jones: inquire into her current health
status, body systems, mental health, and psychosocial history. Regardless of whether you have
assessed Tina previously, ask all questions that are medically relevant to understanding her current
health status. In addition to collecting subjective data, you will perform a physical exam on Ms. Jones
systems to gather objective data about her overall health. Ms. Jones has no new abnormal findings, so
after you complete an exam task, you do not need to make selections in the Electronic Health Record,
though you may document your findings if you like. While you should communicate with patients
using accessible, everyday language, it is standard practice to use professional medical terminology
everywhere else, such as in documenting physical findings and nursing notes. You may complete the
exam activities in any order and move between them as needed.

Your Avatar. What else will this exam involve? Question

11/11/24 10:24 AM EST

Character avatar. You will complete nursing tasks to protect the patients safety, privacy, and
health. While it is not required for this assignment, you can document your findings, including vital
signs, in the Electronic Health Record. This record provides necessary information for healthcare
professionals who will continue patient care. Activities other than Subjective and Objective Data
Collection, such as Documentation and Education and Empathy, provide valuable practice for their
real-world counterparts. However, they are not automatically graded by the simulation.




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,10/16/24, 11:44 Tina Jones Comprehensive Assessment Transcript, Subjective,
AM Objective…




Your Avatar. How will I be evaluated? Question

11/11/24 10:25 AM EST

Character avatar. In this assignment, you will be evaluated on your Subjective and Objective
Data Collection. The evaluation of your interview is dependent on how you word your questions
therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth.
The evaluation of your physical exam requires you only to complete all exam actions. Documentation
of the exam is encouraged, as it can provide you valuable real-world experience, but they are not
automatically graded by the simulation. This assignment takes on average between 140 and 170
minutes. You can pause and resume the assignment at any time; your work is always saved
automatically.
Your Avatar. How does this assignment prepare me for the real world? Question

11/11/24 10:25 AM EST

Character avatar. In this assessment, you will become familiarized with the structure and
content of comprehensive assessments so that with real-life patients, you can: º develop a mental
model for sequencing a comprehensive exam º ask effective and comprehensive questions º evaluate
the patients risk of disease, infection, injury, and complications º and document data with
professional terminology.

Character avatar. In 1 or 2 sentences, answer this question to help prepare for the upcoming
exam: How does interviewing a healthy patient differ from interviewing a patient with a known
health condition?

Your Avatar. Interviewing a healthy patient involves a comprehensive inquiry into why they are at
the clinic. Interviewing a patient with a known health condition requires a comprehensive health
assessment and more background into signs and symptoms surrounding their known health condition.
Statement
11/11/24 10:27 AM

EST

Character avatar. Time to begin.

Your Avatar. Good Morning. I am Nurse Billy and will be taking care of your today. Greet

11/11/24 11:16 AM EST

Tina Jones. Hey.

Your Avatar. Can you please state your name and date of birth. Question

11/11/24 11:17 AM EST

Tina Jones. My name's Tina Jones, and my birthday's February 17th.
Your Avatar. Thank you. Empathize

11/11/24 11:17 AM EST




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,10/16/24, 11:44 Tina Jones Comprehensive Assessment Transcript, Subjective,
AM Objective…




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, 10/16/24, 11:44 Tina Jones Comprehensive Assessment Transcript, Subjective,
AM Objective…




11/11/24 11:21 AM EST

Tina Jones. Thanks.

Your Avatar. What helps with the gas? Question

11/11/24 11:22 AM EST

Tina Jones. Mostly things just settled down in my life. I got a new job, and school is over, and I
passed my exam. I have a new boyfriend. Things are just in a better place.

Your Avatar. Do you eat yogurt? (No matching questions found.) Question

11/11/24 11:23 AM EST

Your Avatar. Do you eat pro-biotics? (No matching questions found.) Question

11/11/24 11:24 AM EST

Your Avatar. Do you take pro-biotics? Question

11/11/24 11:24 AM EST

Tina Jones. I'm really careful to take it every day.

Your Avatar. How often do you take metformin? Question
11/11/24 11:24 AM EST

Tina Jones. I take it twice a day.

Your Avatar. What is your current dose? Question

11/11/24 11:24 AM EST

Tina Jones. It's 850 mg. And I take one pill, twice a day.

Your Avatar. What type of inhaler do you use? Question
11/11/24 11:25 AM EST

Tina Jones. It's an albuterol inhaler.

Your Avatar. Do you use a rescue inhaler? (Clarified to Do you have a rescue inhaler?.)
Question

11/11/24 11:25 AM EST

Tina Jones. Yeah, I have my Proventil inhaler just in case. (Clarified to if I have a rescue inhaler.)

Your Avatar. When was the last time you used your proventil inhaler? Question

11/11/24 11:26 AM EST

Tina Jones. Yesterday. I ran up the stairs a little too fast.




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