NURS 6512: Advanced Health Assessment & Diagnostic Reasoning – Assignment Brief

Assessment 4: Shadow Health Comprehensive Physical Assessment (Tina Jones) and SOAP Note

Weighting: 40%

Length: 5–8 pages (standardized SOAP template)

Submission Format: Shadow Health Lab Pass (PDF) and Professional Documentation (Word Document)

Due Date: Day 7, Week 9, by 23:59 (Mountain Time)

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1. Assessment Context

The comprehensive health assessment is the foundation of advanced practice nursing. This assessment requires you to transition from basic assessment skills to advanced diagnostic reasoning. Using the Shadow Health virtual simulation environment, you will perform a head-to-toe physical examination on Tina Jones, a 28-year-old patient. The goal is to accurately identify all health findings, prioritize potential diagnoses, and develop an evidence-based plan of care that addresses both acute and chronic health needs.

2. Task Description

This assessment is divided into two mandatory components. Failure to submit both will result in an incomplete grade for the week.

Part 1: Shadow Health Virtual Simulation

Complete the “Comprehensive Physical Assessment” module in Shadow Health. You are expected to:

• Perform a complete History of Present Illness (HPI) and a full Review of Systems (ROS).
• Conduct a head-to-toe physical exam (Integumentary, HEENT, Respiratory, Cardiovascular, Gastrointestinal, Genitourinary, Musculoskeletal, and Neurological systems).
• Achieve a minimum Digital Clinical Experience (DCE) score of 80% or higher to demonstrate clinical competency.

Part 2: Professional SOAP Note Documentation

Translate your virtual encounter into a professional clinical document using the Comprehensive SOAP Template. Narrative summaries must be concise yet thorough, avoiding “within normal limits” (WNL) in favor of descriptive findings.

• Subjective Data: Document the CC, HPI (using OLDCARTS or LOCATES), PMH, Family History, Social History, and a detailed ROS.
• Objective Data: Record physical examination findings for every system. Include vital signs and any diagnostic results provided in the simulation.
• Assessment: List one primary diagnosis and at least three differential diagnoses. You must provide a clear rationale for why you chose the primary diagnosis and why you ruled out the differentials based on evidence.
• Plan: Develop a management plan including further diagnostics, pharmacological and non-pharmacological interventions, patient education, and follow-up instructions.

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3. Requirements and Formatting

• Documentation Style: Professional medical language is required. Use clinical terminology (e.g., “normocephalic, atraumatic” instead of “head looks fine”).
• Differential Diagnoses: Each differential must be supported by a minimum of one peer-reviewed reference.
• Templates: You must use the provided Walden University SOAP template. Remove all instructional blue text before submission.
• APA 7th Edition: Required for the reference list and in-text citations within the Assessment and Plan sections.

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4. Scoring Rubric / Marking Criteria

Criteria	Distinction (A)	Commendable (B)	Satisfactory (C)	Unsatisfactory (F)
DCE Score & Lab Pass (20%)	Achieves 90%+ score. All simulation requirements met.	Achieves 80–89% score. Most simulation requirements met.	Achieves 70–79% score. Some simulation gaps.	DCE score below 70% or Lab Pass not submitted.
Subjective & Objective Data (30%)	Exceptional detail in HPI and ROS. Objective findings are descriptive, precise, and professional.	Clear data provided. Professional tone maintained with minor omissions in detail.	Data is present but lacks descriptive depth or contains “WNL” shortcuts.	Incomplete history or physical exam data.
Diagnostic Reasoning (30%)	Primary diagnosis is highly accurate. Differentials are logical and supported by robust evidence.	Correct primary diagnosis. Differentials are relevant but support could be stronger.	Diagnosis is plausible but lacks evidence-based justification.	Incorrect diagnosis or no differentials provided.
Plan & Health Promotion (20%)	Comprehensive plan covering all five domains (Diagnostics, Meds, Education, Referral, Follow-up).	Logical plan addressing major issues, though some educational details may be sparse.	Plan is generic or lacks specific evidence-based interventions.	Inadequate or unsafe management plan.

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Advanced practice nurses utilize the SOAP note format to organize clinical findings and guide diagnostic reasoning during the comprehensive health assessment of complex patients like Tina Jones. Proper documentation of the History of Present Illness (HPI) ensures that every symptom attribute including location, onset, character, and severity is captured to narrow the list of differential diagnoses effectively. Clinicians must synthesize subjective data with objective physical examination findings to justify a primary diagnosis and an evidence-based management plan. Effective health assessment requires a deep understanding of the physiological and psychosocial factors that influence patient presentations in a primary care setting (Ball et al., 2023).

Learning Materials and Resources

• Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., and Stewart, R. W. (2023) Seidel’s Guide to Physical Examination: An Interprofessional Approach. 10th edn. St. Louis, MO: Elsevier. Available at: https://www.elsevier.com/books/seidels-guide-to-physical-examination/ball/978-0-323-76183-3.
• Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., and Soriano, R. P. (2021) Bates’ Guide to Physical Examination and History Taking. 13th edn. Philadelphia, PA: Wolters Kluwer.
• Dains, J. E., Baumann, L. C., and Scheibel, P. (2019) Advanced Health Assessment and Clinical Diagnosis in Primary Care. 6th edn. St. Louis, MO: Elsevier. doi: 10.1016/C2016-0-04374-1.
• Sullivan, D. D. (2024) Guide to Clinical Documentation. 4th edn. Philadelphia, PA: F.A. Davis Company.