NURS 6512 Module 2 week 4 Simulation Case Study #2: Comprehensive Health History and a Focused Physical Examination

NURS 6512 Module 2 week 4 Simulation Case Study #2: Comprehensive Health History and a Focused Physical Examination

Module 2: General, HEENT, Neck, and Skin

Simulation Case Study #2: Comprehensive Health History and a Focused Physical Examination

Simulation case studies can help you strengthen your advanced assessment and documentation skills, supporting accurate clinical reasoning and prepare you for future patient encounters. This simulation assignment allows you to demonstrate your ability to collect and document both subjective and objective data during a comprehensive health assessment.

Level 1: No AI Permitted

AI tools may 
not
 be used at any stage

Common for clinical documentation or performance‑based work

Resources

 

Be sure to review the Learning Resources before completing this assessment.

Required Resources

To prepare:

Review Learning Resources in Weeks 1–4.

Download and review the “
Comprehensive Health History Reference Sheet
” and the “
Physical Exam Reference Sheet
 
Download
.”

Access 
Simulation Case Study #2: Painful Rash

Review current evidence-based guidelines related to the patient complaint.

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.

NURS 6512 Module 2 week 4 Simulation Case Study #2: Comprehensive Health History and a Focused Physical Examination

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.

By Sunday of Week 4

Submit
 your Assignment.

Submission Information

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Rubric

NURS_6512_Module2_Assignment_Rubric

NURS_6512_Module2_Assignment_Rubric

Criteria

Ratings

Pts

This criterion is linked to a Learning Outcome
Part I: Comprehensive Health History (Subjective Data Only)… Demonstrates accurate and complete documentation of patient comprehensive health history (subjective data only) NURS 6512 Module 2 week 4 Simulation Case Study #2: Comprehensive Health History and a Focused Physical Examination.

25
 
to >
22.35
 pts
Excellent
Provides accurate and complete documentation of patient comprehensive health history (subjective data only).

22.35
 
to >
19.85
 pts
Good
Provides a mostly accurate and complete patient comprehensive health history (subjective data only); may contain some minor errors.

19.85
 
to >
0
 pts
Poor
Does not provide documentation of patient health history (subjective data only); documentation is inaccurate and/or incomplete.

25
 pts

This criterion is linked to a Learning Outcome
Part II: Focused Physical Examination (Objective Data Only)… Demonstrates accurate and complete documentation of patient focused physical examination (objective data only).

25
 
to >
22.35
 pts
Excellent
Provides accurate and complete documentation of patient focused physical examination (objective data only).

22.35
 
to >
19.85
 pts
Good
Provides a complete, mostly accurate documentation of patient focused physical examination (objective data only); may contain some minor errors.

19.85
 
to >
0
 pts
Poor
Does not provide documentation of patient focused physical examination (objective data only); data provided is inaccurate and/or incomplete.

25
 pts

This criterion is linked to a Learning Outcome
Part III: Reflection Section 1: Subjective vs. Objective Distinction…Identify two examples where it may have been challenging to separate subjective from objective data; Explain how you ensured that patient-reported symptoms remained in the history section; Explain how you ensured that only observable or measurable findings were included in the physical exam section.

15
 
to >
13.41
 pts
Excellent
Provides two fully developed examples of situations that posed a challenge separating subjective and objective data… Fully explains how they ensured that patient-reported symptoms remained in the history section… Fully explains how they ensured that only observable or measurable findings were included in the physical exam section.

13.41
 
to >
11.91
 pts
Good
Provides two adequately developed examples of situations that posed a challenge separating subjective and objective data… Adequately explains how they ensured that patient-reported symptoms remained in the history section… Adequately explains how they ensured that only observable or measurable findings were included in the physical exam section.

11.91
 
to >
0
 pts
Poor
Does not provide examples of situations that posed a challenge separating subjective and objective data; explanations are unclear or incomplete.

15
 pts

This criterion is linked to a Learning Outcome
Part III: Reflection Section 2: Additional Assessment Questions… Identify 2–3 additional questions you would ask to strengthen your subjective assessment…. For each question: State the question; Briefly explain why it is important; Describe how the response could guide your focused physical examination

10
 
to >
8.94
 pts
Excellent
Identifies 2–3 additional questions they would ask to strengthen their subjective assessment… Provides a fully developed explanation of why the question is important… Provides a fully developed description of how the response could guide their focused examination.

8.94
 
to >
7.94
 pts
Good
Identifies 2–3 additional questions they would ask to strengthen their subjective assessment… Provides an adequately developed explanation of why the question is important… Provides an adequately developed description of how the response could guide their focused examination. NURS 6512 Module 2 week 4 Simulation Case Study #2: Comprehensive Health History and a Focused Physical Examination

7.94
 
to >
0
 pts
Poor
Does not identify 2–3 additional questions they would ask to strengthen their subjective assessment; the questions provided are unclear, inaccurate, or incomplete.

10
 pts

This criterion is linked to a Learning Outcome
Part III: Reflection… Section 3: Professional Growth… Identify one area of your assessment skills that you would like to improve (e.g., documenting vesicular lesions, describing rash morphology, lymph node assessment). Briefly explain how you plan to strengthen that skill.

10
 
to >
8.94
 pts
Excellent
Identifies one area of their assessment skills they would like to improve… Provides a fully developed explanations of how they plan to strengthen that skill.

8.94
 
to >
7.94
 pts
Good
Identifies one area of their assessment skills they would like to improve… Provides an adequately developed explanations of how they plan to strengthen that skill.

7.94
 
to >
0
 pts
Poor
Does not identify one area of assessment skills they would like to improve; explanation is unclear, inaccurate, or incomplete.

10
 pts

This criterion is linked to a Learning Outcome
Uses at least 3 scholarly resources that are less than 5 years old.

5
 
to >
4.46
 pts
Excellent
Uses 3 peer-reviewed scholarly sources published within the last 5 years.

4.46
 
to >
3.96
 pts
Good
Uses 2 peer-reviewed scholarly sources published within the last 5 years.

3.96
 
to >
3.46
 pts
Fair
Uses 1 peer-reviewed scholarly source published within the last 5 years.

3.46
 
to >
0
 pts
Poor
Does not use peer-reviewed scholarly sources or sources used are older than 5 years.

5
 pts

This criterion is linked to a Learning Outcome
Source Attribution and APA Formatting

5
 
to >
4.46
 pts
Excellent
All sources are cited in APA format without any errors.

4.46
 
to >
3.96
 pts
Good
All sources are cited in APA format with some minor errors.

3.96
 
to >
3.46
 pts
Fair
All sources are cited with frequent APA formatting errors.

3.46
 
to >
0
 pts
Poor
Missing source citations and/or minimal adherence to APA formatting rules.

5
 pts

This criterion is linked to a Learning Outcome
Grammar, Mechanics, and Punctuation

NURS 6512 Module 2 week 4 Simulation Case Study #2: Comprehensive Health History and a Focused Physical Examination

5
 
to >
4.46
 pts
Excellent
Correct grammar, spelling, and punctuation with no errors.

4.46
 
to >
3.96
 pts
Good
Correct grammar, spelling, and punctuation with few errors.

3.96
 
to >
3.46
 pts
Fair
Correct grammar, spelling, and punctuation with frequent errors.

3.46
 
to >
0
 pts
Poor
Frequent errors in grammar, spelling, and punctuation that interfere with comprehension.

5
 pts

Total Points: 
100