Title:
Documentation of downside primarily based evaluation of the neurological system.
Objective of Project:
Studying the required parts of documenting an issue primarily based subjective and goal evaluation of neurological system. Determine irregular findings.
Course Competency:
Apply evaluation methods for the neurological and respiratory techniques.
Directions:
Content material: Use of three sections:
o Subjective
o Goal
o Precise or potential danger elements for the shopper primarily based on the evaluation findings with description or purpose for choice of them.
Format:
• Customary American English (appropriate grammar, punctuation, and so forth.)
Assets:
Chapter 5: SOAP Notes: The subjective and goal portion solely
Sullivan, D. D. (2012). Information to medical documentation. [E-Book]. Retrieved from http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=nlebk&AN=495456&web site=eds-live&ebv=EB&ppid=pp_91
Smith, L. S. (2001, September). Documentation do’s and don’ts. Nursing, 31(9), 30. Retrieved from http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=107055742&web site=eds-live
Documentation Grading Rubric- 10 potential factors
Ranges of Achievement
Standards Rising Competence Proficiency Mastery
Subjective
(four Pts) Lacking parts similar to biographic information, medicines, or allergy symptoms. Signs evaluation is incomplete. Could include goal information.
Fundamental biographic information offered. Drugs and allergy symptoms included. Signs evaluation incomplete. Missing element. No goal information. Fundamental biographic information offered. Included listing of medicines and allergy symptoms. Signs evaluation: PQRSTU accomplished. Missing element. No goal information. Data is solely what “shopper” offered. Fundamental biographic information offered. Included listing of medicines and allergy symptoms. Signs evaluation: PQRSTU accomplished. Detailed. No goal information. Data is solely what “shopper” offered.
Factors: 1 Factors: 2 Factors: three Factors:four
Goal
(four Pts) Lacking parts of evaluation for specific system. Could include subjective information. Could have indicators of bias or rationalization of findings. Could have included phrases similar to “regular”, “acceptable”,
“okay”, and “good”.
Contains all parts of evaluation for specific system. Lacks element. Makes use of phrases similar to “regular”, “acceptable”, or “good”. Incorporates all goal data. Could have indicators of bias or rationalization of findings. Contains all parts of evaluation for specific system. Prevented use of phrases similar to “regular”, “acceptable”, or “good”. No bias or rationalization for findings evident Incorporates all goal data Contains all parts of evaluation for specific system. Detailed data offered. Prevented use of phrases similar to “regular”, “acceptable”, or “good”. No bias or rationalization for findings evident. All goal data
Factors: 1 Factors: 2 Factors: three Factors: four
Precise or Potential Threat Elements
(2 pts)
Lists one to 2 precise or potential danger elements for the shopper primarily based on the evaluation findings with no description or purpose for choice of them. Failure to offer any potential or precise danger elements will end in zero factors for this criterion. Temporary description of 1 or two precise or potential danger elements for the shopper primarily based on evaluation findings with description or purpose for choice of them. Restricted description of two precise or potential danger elements for the shopper primarily based on the evaluation findings with description or purpose for choice of them. Complete, detailed description of two precise or potential danger elements for the shopper primarily based on the evaluation findings with description or purpose for choice of them.
Factors: zero.5 Factors: 1 Factors: 1.5 Factors: 2
