NURS 6512: Assessment Reference Sheet

Purpose

To guide you in writing a clear, logical Assessment, including differential diagnoses, one final diagnosis supported by evidence, and required references supporting clinical reasoning.

Overview of Expectations

-  Include 3–5 differential diagnoses.

-  Select ONE final diagnosis.

-  Support all reasoning with subjective and objective findings.

-  Use professional, concise clinical language.

-  Include 3–5 peer

reviewed references (≤5 years old) to support diagnostic reasoning.

Differential Diagnoses (3–5 Required)

Differential #1 Condition:

Rationale:

Subjective findings (supporting):

-                  

Subjective findings (non-supporting/absent):

-                  

Objective findings (supporting):

-                  

Objective findings (non-supporting/absent):

-                  

Differential #2 Condition:

Rationale:

Subjective findings (supporting):

-                  

Subjective findings (non-supporting/absent):

-                  

Objective findings (supporting):

-                  

Objective findings (non-supporting/absent):

-                  

Differential #3 Condition:

Rationale:

Subjective findings (supporting):

-                  

Subjective findings (non-supporting/absent):

-                  

Objective findings (supporting):

-                  

Objective findings (non-supporting/absent):

-                  

Differential #4 (Optional)

Differential #5 (Optional)

Final Diagnosis (ONE ONLY)

Final Diagnosis: [Write the final diagnosis here]

Final Problem Statement Template

[Initials/Name], [Age], presents with [chief complaint] characterized by [positive subjective findings] and denies [negative subjective findings]. Physical exam reveals [positive objective findings] with absence of [negative objective findings]. Pertinent history includes [relevant PMH, family history, or risk factors]. The overall clinical picture is most consistent with [final diagnosis].

Reference Requirements

You must include 3–5 peer-reviewed journal references (published within the last 5 years) to support diagnostic reasoning in the Assessment. References must:

-  Align with the differential diagnoses and/or final diagnosis.

-  Support pathophysiology, clinical presentation, or diagnostic criteria.

-  Be cited in APA 7th edition format.

-  Not include textbooks, blogs, or patient-education websites.

  

Example acceptable sources:

-  Peer-reviewed journal articles

-  Clinical practice guidelines (ACC/AHA, ADA, IDSA, AAP, USPSTF)

-  Systematic reviews or meta-analyses