What Is Shadow Health?
Shadow Health is a library of screen-based clinical simulations, called Digital Clinical Experiences (DCEs), in which you interview and examine virtual patients. Elsevier calls these patients Digital Standardized Patients, and its patented Conversation Engine lets you type questions in your own words instead of picking them from a menu.
The company was founded in Gainesville, Florida, in 2011 as a University of Florida startup, and Elsevier acquired Shadow Health in December 2020. Elsevier now says more than 700,000 nursing students use it. You will often see the name typed as one word, Shadowhealth, which matches the shadowhealth.com web address. It is the same product.
Elsevier offers DCEs in 11 undergraduate collections: Community Health, Fundamentals, Gerontology, Health Assessment, Leadership, Maternal Health, Medical-Surgical Nursing, Mental Health, Pathophysiology, Pediatrics and Pharmacology. Graduate students meet it in courses such as Advanced Health Assessment and Advanced Pharmacology. When classmates talk about "the Shadow Health assessment," they usually mean an assignment from the Health Assessment collection.
What Happens in a Digital Clinical Experience
Most patient assignments follow the same shape, although your instructor decides which parts are switched on.
- Interview. You take a history by typing questions to the patient. Everything the patient tells you is your subjective data.
- Physical exam. You perform exam actions such as inspection, palpation, percussion and auscultation on each body region. What you observe and measure is your objective data.
- Documentation. You record findings in the simulation's electronic health record (EHR).
- Post-exam activities. Depending on the case, these can include a care plan, nursing diagnoses, patient education or self-reflection prompts.
- Results. You get scores and feedback right away, unless your instructor delays detailed feedback until after the due date.
How Is a Shadow Health Assessment Scored?
A Shadow Health assessment with a patient exam produces two headline numbers: the DCE score, which is the percentage Shadow Health recommends for grading, and the Student Performance Index (SPI), which measures the clinical reasoning underneath it. Shadow Health's support article on DCE and SPI scores explains how they relate.
- SPI: your raw points earned out of points possible, measured against what a high-performing graduate does on a model exam. Shadow Health does not recommend grading on the raw SPI because it is not normalized against a national average.
- DCE score: when the SPI is used, the DCE score compares your SPI with the national average and standard deviation for the same assignment, with the mean set at 80%. This is the score Shadow Health recommends for grading.
- Proficiency level: Beginning (the bottom 50% of a representative student group), Developing (the next 25%) or Proficient (the top 25%).
In plain terms, a DCE score near 80% means you did about as well as the typical student nationally on that case. That is not a failing mark. Your instructor decides how the DCE score turns into a course grade and may grade your documentation or a reflection paper separately, so check the syllabus before you assume anything.
What Each Section of Your Results Measures
The SPI always includes subjective and objective data collection. Other sections appear only when an assignment uses them. Here is what Shadow Health's Experience Overview page shows you after an attempt.
| Results Section | What It Measures | What It Means for You |
|---|
| Subjective Data Collection | The share of essential interview items you uncovered | Grey items were available, but you never asked about them |
| Objective Data Collection | Accuracy and completeness of each physical assessment | Most assignments give partial credit, but the Comprehensive Assessment requires full completion for credit |
| Education and Empathy | Whether you spotted and followed up on teaching and empathy opportunities | You earn the points only if you respond within two interactions |
| Documentation | Your EHR entries as recorded during the exam | Your instructor can open your full results, so write it like a real chart |
| Care Plan or Information Processing | Priorities, evidence and plans for relevant diagnoses | Appears only in assignments that include these activities |
| Self-Reflection | Your answers to journaling prompts | Shadow Health does not grade these, but your instructor may |
The results page also tracks three kinds of time: overall time, exam time spent in the room with the patient and post-exam time.
Settings Your Instructor Controls
Two students in different courses can face very different rules for the same case, because instructors choose the assignment options. Look for these in your instructions:
- Mastery Learning or Clinical Reasoning Check. Mastery Learning gives you immediate feedback so you can fix gaps. Clinical Reasoning Check is designed to separate below-average, average and above-average performance.
- Flexible Turn-in. You can make several fresh attempts before the due date, and only the attempt you submit is visible to your instructor.
- Reopen. You can go back into the room to ask more questions or finish the exam. It keeps your previous answers and disappears once the due date passes.
- Interview Guide. Set to Full, Partial or None. With None, you get no guidance during subjective data collection.
- Delay Detailed Feedback. Your in-depth feedback stays hidden until after the due date.
- Lab Pass. If your instructor turns it on, a PDF certificate with your name, the assignment and your scores, which some instructors ask you to upload.
Common Shadow Health Cases: Tina Jones, Esther Park and More
The Health Assessment collection pairs each assignment with a named patient, and Elsevier's current Health Assessment lineup looks like this. Elsevier revises cases over time (an Integumentary exam has already replaced the old Skin, Hair and Nails module), so your course may show different patients or an older version. Your course's assignment list is the final word.
| Assignment | Patient | What It Focuses On |
|---|
| Health History | Tina Jones | A full health interview after an admission for IV antibiotics following a right foot injury |
| Respiratory System | Yuki Morimoto | An adult with an asthma exacerbation in the emergency department |
| Cardiovascular System | Rochelle Joseph | A pregnancy follow-up for a patient with a recent mitral valve prolapse diagnosis |
| HEENT System | Kellan Clarke | A teenager with a sore throat, including parental consent and patient assent |
| Abdominal System | Martin Francis | Abdominal symptoms after travel and norovirus exposure |
| Musculoskeletal System | Ezra Levy | A teenager with right ankle pain and injury |
| Neurological System | Samuel Green | An older adult with foot pain, unsteady gait and memory loss |
| Integumentary System | Lupe Sosa | A rash on the right forearm |
| Focused Exam: Cough | Danny Rivera | A child in a school nurse's office, with a phone call to his guardian |
| Focused Exam: Abdominal Pain | Esther Park | Abdominal pain at Shadow General Hospital, with genitourinary and cardiovascular systems as secondary |
| Focused Exam: Chest Pain | Brian Foster | Chest pain in a hospitalized post-surgical patient whose vital signs change |
| Focused Exam: Comprehensive Assessment | Tina Jones | A head-to-toe exam for a pre-employment physical |
The Tina Jones Comprehensive Assessment
The Tina Jones comprehensive assessment pulls every body system from the course into one visit. Six months after her hospital admission, her foot wound has healed, and she comes to the clinic for a complete health assessment for a pre-employment physical. You perform a full head-to-toe exam to show clinical competency.
Two details matter more here than anywhere else. First, the optional Plan My Exam activity asks you to arrange exam actions into a sequence that moves smoothly from head to toe before you start. Second, objective data collection requires full completion for credit in this assignment, while most other cases give partial points. Skipping one part of an assessment can cost you the credit for that assessment, so finish every region before you move on.
Her earlier Health History assignment works differently. There you build an interview from her context, document in the EHR, identify nursing diagnoses from your data, and plan interventions and patient education. If your course adds a care plan, our guide to writing a nursing diagnosis shows the format step by step.
Esther Park: Abdominal Pain and Cognition
Esther Park appears in two different assignments, so check which one you have. In Health Assessment's Focused Exam: Abdominal Pain, she presents at Shadow General Hospital, and you take a focused history that covers diet, toilet habits, immunizations, travel, and surgical, reproductive and sexual history. You also watch for verbal and non-verbal cues, because she shows discomfort during palpation.
The case includes an exam order review, so know the abdominal sequence before you begin. Open RN's abdominal assessment chapter explains why: palpation comes after you auscultate bowel sounds, so the sounds you hear are not disturbed. The Gerontology collection has a separate Focused Exam: Cognition with Esther Park, which tests a different set of skills.
Other Focused Exams
Danny Rivera's cough exam centers on the respiratory system, with HEENT and cardiovascular as secondary systems, and asks about home life, such as second-hand smoke exposure. Brian Foster's chest pain exam is an emergent case: his vital signs change, and you are expected to notify the preceptor. Practice a structured handoff such as SBAR (Situation, Background, Assessment and Recommendation) before you start.
How to Prepare Before You Start
Good preparation means knowing the rules of your assignment, the body system you will examine and the order you will work in before the patient says a word.
- Read the instructions and rubric. Note the due date, the number of attempts, whether Reopen is allowed and what else you must submit, such as a Lab Pass, a SOAP note or a reflection paper.
- Review the system. Go back over the anatomy, normal findings and common abnormal findings in your textbook. The Cardiovascular, Respiratory and Abdominal concept labs let you review heart sounds, breath sounds and the abdominal exam first.
- Outline your interview. A comprehensive history covers the areas that Open RN lists: demographic data, reason for seeking care, current and past medical history, family history, functional health and daily activities, and a review of systems.
- Plan your exam order. Write your sequence on paper so you do not jump between regions.
- Block uninterrupted time. One university's health assessment course estimates about 60 minutes for the Esther Park exam. A comprehensive exam covers far more, so give yourself a longer window.
- Keep a findings sheet. Jot findings as you go so documentation later is copying, not remembering.
How to Collect Subjective Data in the Interview
Subjective data is what the patient reports, and in Shadow Health you collect it by typing questions, so the score rewards questions that are specific, complete and followed up. Open RN defines subjective data as information from the patient or family, and that is what the Subjective Data Collection section scores.
- Start open, then narrow. Begin with "What brings you in today?" and let the patient talk. Then ask focused questions about each symptom.
- Ask one thing at a time. Short, single questions make it clear which part the patient answered, and they make your transcript easier to review.
- Cover the whole history. Medications (including over-the-counter drugs and supplements), allergies and the reaction, family history, tobacco, alcohol and drug use, and any area your assignment lists.
- Follow every new symptom. When the patient mentions something new, explore it before you move on. Every symptom you leave unexplored is a chance for an item to stay grey.
A Worked Example: Exploring a Symptom with PQRSTU
Open RN describes the PQRSTU mnemonic for exploring pain and many other symptoms. Here it is applied to a made-up patient who says they have been short of breath. This example is not from any Shadow Health case.
| Letter | What You Are Asking About | Sample Question |
|---|
| P | Provocation and palliation | "What makes your breathing worse? What makes it better?" |
| Q | Quality | "How would you describe it? Is it tightness, or not being able to get a full breath?" |
| R | Region | "Do you feel it anywhere in particular, like your chest or throat?" |
| S | Severity | "On a scale of 0 to 10, how bad is it right now?" |
| T | Timing and treatment | "When did it start? Does it come and go? Have you taken anything for it?" |
| U | Understanding | "What do you think is causing it?" |
Run through all six letters for every symptom the patient raises. It is easy to ask about onset and severity and move on, which leaves the other letters unasked.
Education and Empathy Opportunities
The Education and Empathy score rewards you for noticing a teaching moment or an emotional cue and responding within two interactions. If the patient voices a worry and your next two questions ignore it, the chance is gone.
Here is a made-up exchange that shows the difference:
Patient: "I keep thinking this is going to cost me my new job."
Weak reply: "Okay. Do you have any allergies?"
Stronger reply: "That sounds like a lot of pressure. What worries you most about it?"
Education opportunities work the same way. When a patient shows a gap in understanding about a medication, a habit or a condition, acknowledge it and offer short, plain teaching before you change the subject.
How to Collect Objective Data in the Physical Exam
Objective data is what you observe, measure and hear, and Shadow Health scores each exam action on accuracy and completeness. OpenStax's Clinical Nursing Skills describes it as information gathered through your senses of hearing, sight, smell and touch.
- Work in a fixed order. Start with a general survey and vital signs, then move head to toe and finish one region before starting the next.
- Use every technique the region needs. For most systems that means some mix of inspection, palpation, percussion and auscultation. For the abdomen, inspect and auscultate before you percuss or palpate.
- Compare both sides. Check left against right for pulses, strength, reflexes and breath sounds.
- Record normal and abnormal findings. A normal finding you checked but did not record cannot help your documentation.
- Act on red flags. If vital signs change or the patient worsens, stop, prioritize safety and escalate as your assignment directs.
Remember the Comprehensive Assessment rule. Partial work earns partial points in most cases, but in the Tina Jones comprehensive assessment a region you only half examine may earn nothing.
How to Write Your Shadow Health Documentation and SOAP Note
Good documentation states exactly what you found, keeps what the patient said apart from what you observed and leaves out nothing your exam covered. In Health Assessment, you write it in the simulation's EHR. In Advanced Health Assessment, instructors can switch on full SOAP note fields, and some courses also ask for a written note or reflection outside the platform.
One university's health assessment course, for example, pairs the Esther Park exam with a Lab Pass and an APA-format reflection of at least three pages. If you need formatting help with that kind of paper, see our APA style guide.
Weak vs. Strong Documentation
These lines describe a made-up patient with low back pain, not a Shadow Health case. Notice how the stronger versions are specific enough that another nurse could picture the patient.
| Section | Weak Entry | Stronger Entry |
|---|
| Subjective | Pt has back pain. | Reports "dull, aching" low back pain for 3 days after lifting boxes, 5/10, worse with bending, eased by rest. Denies numbness, tingling, weakness or changes in bladder or bowel control. |
| Objective (back) | Back WNL. | Lumbar spine without visible deformity or swelling. Tenderness to palpation over right paraspinal muscles. Forward flexion limited by pain. Lower extremity strength 5/5 bilaterally. |
| Objective (lungs) | Lungs clear. | Respirations even and unlabored at 16/min. Breath sounds clear in all fields anteriorly and posteriorly. No wheezes, crackles or rhonchi. |
Three habits make the difference. Put the patient's own words in quotation marks, as Open RN advises for subjective data. Write pertinent negatives, such as "denies chest pain," instead of leaving them out. And replace "WNL" or "normal" with the actual finding. If your results show a model note beside yours, compare them line by line and list what you left out.
How to Structure a SOAP Note
- S (Subjective): chief complaint in the patient's words, history of present illness, medical history, medications, allergies, family and social history, and review of systems.
- O (Objective): vital signs, physical exam findings by body system, and any lab or test results.
- A (Assessment): your interpretation, such as nursing diagnoses or a ranked list of possible causes, each tied to specific data from S and O.
- P (Plan): further assessment, interventions, patient education, referrals and follow-up.
The test of a good assessment section is simple: every conclusion should point back to a finding you documented above it.
How to Use Your Shadow Health Results to Improve
Your results page is the best study tool you have, because it shows exactly which questions and exam actions you missed.
- Read the transcript. It records every interaction with the patient, color coded, with a filter for each interaction type. Look for symptoms you never followed up.
- Study the grey items. In Subjective Data Collection, hover over an item to see its clinical significance and example questions. Add those questions to your own interview template.
- Check objective gaps. Note which exam dimensions you missed, then practice them before the next case.
- Use Reopen wisely. If your instructor allows it, reopening an attempt keeps your earlier answers so you can add questions and finish the exam before the due date.
- Save your Lab Pass. Find it under My Results by opening the attempt and clicking the Lab Pass button at the top right. If the button is missing, your instructor may have delayed feedback, and the Lab Pass support article explains when it appears.
Keep one running list of missed items across every assignment. Patterns show up fast, such as always forgetting the social history or skipping percussion, and fixing one pattern helps on every later case.
Getting Shadow Health Assessment Help the Right Way
The right kind of help teaches you to run the interview and write the note yourself, and anything that has someone else log in or hands you a transcript to copy is the wrong kind. A Shadow Health assessment is graded as your own clinical reasoning. Submitting someone else's work breaks your program's academic integrity rules, and it leaves you guessing when you meet a real patient in clinicals.
Answer keys and old transcripts are also a poor bet on their own terms. You type questions in your own words, the score depends on what you uncover and how you respond, and Elsevier revises its cases. A transcript cannot run your exam or write your documentation.
A good nursing tutor can help you in ways that hold up:
- Explain why a finding matters and how it connects to a likely diagnosis.
- Run practice interviews with made-up patients so you build a habit of complete PQRSTU questioning.
- Review documentation you wrote yourself and show you where it is vague or missing negatives.
- Walk through your graded results with you and turn the grey items into a study plan.
- Give feedback on a SOAP note or reflection draft before you submit it.
A tutor should never ask for your login or complete a DCE for you. If you are comparing services, our checklist on how to choose an online tutor covers what to ask first, and you can read more about nursing homework help for care plans and papers.
If you want a nursing tutor to go through your results or review your documentation, you can request a tutoring session and share the parts you want explained.
Frequently Asked Questions
What Is Shadow Health Used for in Nursing School?
Nursing programs use Shadow Health to let you practice interviews, physical exams and documentation on virtual patients before or alongside real clinicals. Courses assign Digital Clinical Experiences from collections such as Health Assessment, Fundamentals, Pharmacology, Mental Health and Pediatrics. Elsevier also says programs may use them to supplement clinical hours, or replace some where educationally justified, so check how your school counts them.
How Is the Shadow Health DCE Score Calculated?
When the Student Performance Index is used, the DCE score takes your raw SPI points and compares them with the national average and standard deviation for the same assignment, with the mean set at 80%. The SPI itself always includes subjective and objective data collection, plus parts like education and empathy or care planning when the assignment has them. Shadow Health recommends the DCE score for grading.
What Is a Good Shadow Health Score?
Because the DCE score is scaled so the national average sits at 80%, anything around 80% is a typical performance and higher scores beat most of your peers. Your proficiency level adds context: Beginning covers the bottom 50% of students, Developing the next 25% and Proficient the top 25%. Your instructor still sets the passing threshold, so read the syllabus.
Can You Retake a Shadow Health Assessment?
It depends on your instructor's settings. With Flexible Turn-in you can make several fresh attempts before the due date, and only the one you submit is visible to your instructor. With Reopen enabled, you can go back into the room to ask more questions or finish the exam, keeping your earlier work. Both options end when the due date passes.
How Long Does a Shadow Health Assignment Take?
Times vary by case and course. One university's health assessment course estimates about 60 minutes for the Esther Park abdominal pain exam, and the head-to-toe Comprehensive Assessment covers far more ground, so set aside more time for it. Shadow Health tracks your overall time, exam time and post-exam time separately, so you can see where the minutes went.
Can Someone Else Do My Shadow Health Assessment for Me?
No. A Shadow Health assessment is graded as your own clinical reasoning, so having someone else log in or copying a sold transcript breaks most nursing programs' academic integrity rules. It also leaves you unprepared for real patients. A tutor can legitimately explain findings, run practice interviews with made-up cases and review documentation you wrote yourself.
Client Reviews
