Title:
\nDocumentation of problem based assessment of the head, ears, and eyes.<\/p>\n
Purpose of Assignment:
\nLearning the required components of documenting a problem based subjective and objective assessment of a head, ears, and eyes. Identify abnormal findings.<\/p>\n
Course Competency:
\nDemonstrate physical examination skills of the head, ears, and eyes, nose, mouth, neck, and regional lymphatics.<\/p>\n
Instructions:<\/p>\n
Content: Use of three sections:
\no\tSubjective
\no\tObjective
\no\tActual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.<\/p>\n
Format:
\n\u2022\tStandard American English (correct grammar, punctuation, etc.)<\/p>\n
Resources:<\/p>\n
Chapter 3: SOAP Notes (subjective and objective only)
\nSullivan, D. (2018). Guide to clinical documentation. https:\/\/ebookcentral.proquest.com\/lib\/ras\/detail.action?docID=5553403<\/p>\n
Smith, L. S. (2001, September). Documentation do\u2019s and don\u2019ts. Nursing, 31(9), 30. Retrieved from http:\/\/ezproxy.rasmussen.edu\/login?url=http:\/\/search.ebscohost.com\/login.aspx?direct=true&db=rzh&AN=107055742&site=eds-live<\/p>\n
Documentation Grading Rubric- 10 possible points
\nLevels of Achievement
\nCriteria\tEmerging\tCompetence \tProficiency\tMastery
\nSubjective
\n(4 Pts)\tMissing components such as biographic data, medications, or allergies. Symptoms analysis is incomplete. May contain objective data.
\nBasic biographic data provided. Medications and allergies included. Symptoms analysis incomplete. Lacking detail. No objective data. \tBasic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Lacking detail. No objective data. Information is solely what \u201cclient\u201d provided.\tBasic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Detailed. No objective data. Information is solely what \u201cclient\u201d provided.
\nPoints: 1\tPoints: 2\tPoints: 3\tPoints: 4
\nObjective
\n(4 Pts)\tMissing components of assessment for particular system. May contain subjective data. May have signs of bias or explanation of findings. May have included words such as \u201cnormal\u201d, \u201cappropriate\u201d,
\n\u201cokay\u201d, and \u201cgood\u201d.
\nIncludes all components of assessment for particular system. Lacks detail. Uses words such as \u201cnormal\u201d, \u201cappropriate\u201d, or \u201cgood\u201d. Contains all objective information. May have signs of bias or explanation of findings. \tIncludes all components of assessment for particular system. Avoided use of words such as \u201cnormal\u201d, \u201cappropriate\u201d, or \u201cgood\u201d. No bias or explanation for findings evident Contains all objective information\tIncludes all components of assessment for particular system. Detailed information provided. Avoided use of words such as \u201cnormal\u201d, \u201cappropriate\u201d, or \u201cgood\u201d. No bias or explanation for findings evident. All objective information
\nPoints: 1\tPoints: 2\tPoints: 3\tPoints: 4
\nActual or Potential Risk Factors
\n(2 pts)
\nLists one to two actual or potential risk factors for the client based on the assessment findings with no description or reason for selection of them. Failure to provide any potential or actual risk factors will result in zero points for this criterion.\tBrief description of one or two actual or potential risk factors for the client based on assessment findings with description or reason for selection of them.\tLimited description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.\tComprehensive, detailed description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.
\nPoints: 0.5\tPoints: 1\tPoints: 1.5\tPoints: 2<\/p>\n","protected":false},"excerpt":{"rendered":"
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