Title:
Documentation of downside primarily based evaluation of the pinnacle, ears, and eyes.
Function of Project:
Studying the required parts of documenting an issue primarily based subjective and goal evaluation of a head, ears, and eyes. Establish irregular findings.
Course Competency:
Display bodily examination expertise of the pinnacle, ears, and eyes, nostril, mouth, neck, and regional lymphatics.
Directions:
Content material: Use of three sections:
· Subjective
· Goal
· Precise or potential danger components for the shopper primarily based on the evaluation findings with description or cause for collection of them.
Format:
· Customary American English (appropriate grammar, punctuation, and so on.)
Assets:
Chapter three: SOAP Notes (subjective and goal solely)
Sullivan, D. (2018). Information to medical documentation. https://ebookcentral.proquest.com/lib/ras/element.motion?docID=5553403
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 comparable to biographic information, drugs, or allergy symptoms. Signs evaluation is incomplete. Could comprise 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 explicit system. Could comprise subjective information. Could have indicators of bias or clarification of findings. Could have included phrases comparable to “regular”, “applicable”, “okay”, and “good”.
Contains all parts of evaluation for explicit system. Lacks element. Makes use of phrases comparable to “regular”, “applicable”, or “good”. Incorporates all goal data. Could have indicators of bias or clarification of findings.
Contains all parts of evaluation for explicit system. Averted use of phrases comparable to “regular”, “applicable”, or “good”. No bias or clarification for findings evident Incorporates all goal data
Contains all parts of evaluation for explicit system. Detailed data offered. Averted use of phrases comparable to “regular”, “applicable”, or “good”. No bias or clarification for findings evident. All goal data
Factors: 1
Factors: 2
Factors: three
Factors: four
Precise or Potential Danger Elements
(2 pts)
Lists one to 2 precise or potential danger components for the shopper primarily based on the evaluation findings with no description or cause for collection of them. Failure to supply any potential or precise danger components will end in zero factors for this criterion.
Temporary description of 1 or two precise or potential danger components for the shopper primarily based on evaluation findings with description or cause for collection of them.
Restricted description of two precise or potential danger components for the shopper primarily based on the evaluation findings with description or cause for collection of them.
Complete, detailed description of two precise or potential danger components for the shopper primarily based on the evaluation findings with description or cause for collection of them.
Factors: zero.5
Factors: 1
Factors: 1.5
Factors: 2
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