Title:
Documentation of drawback based mostly evaluation of the neurological system.
Goal of Project:
Studying the required elements of documenting an issue based mostly subjective and goal evaluation of neurological system. Determine irregular findings.
Course Competency:
Apply evaluation methods for the neurological and respiratory methods.
Directions:
Content material: Use of three sections:
o Subjective
o Goal
o Precise or potential threat elements for the consumer based mostly on the evaluation findings with description or motive for choice of them.
Format:
• Customary American English (appropriate grammar, punctuation, and so on.)
Sources:
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 doable factors
Ranges of Achievement
Standards Rising Competence Proficiency Mastery
Subjective
(four Pts) Lacking elements resembling biographic knowledge, drugs, or allergic reactions. Signs evaluation is incomplete. Could comprise goal knowledge.
Primary biographic knowledge supplied. Medicines and allergic reactions included. Signs evaluation incomplete. Missing element. No goal knowledge. Primary biographic knowledge supplied. Included record of medicines and allergic reactions. Signs evaluation: PQRSTU accomplished. Missing element. No goal knowledge. Info is solely what “consumer” supplied. Primary biographic knowledge supplied. Included record of medicines and allergic reactions. Signs evaluation: PQRSTU accomplished. Detailed. No goal knowledge. Info is solely what “consumer” supplied.
Factors: 1 Factors: 2 Factors: three Factors:four
Goal
(four Pts) Lacking elements of evaluation for specific system. Could comprise subjective knowledge. Could have indicators of bias or clarification of findings. Could have included phrases resembling “regular”, “acceptable”,
“okay”, and “good”.
Contains all elements of evaluation for specific system. Lacks element. Makes use of phrases resembling “regular”, “acceptable”, or “good”. Incorporates all goal data. Could have indicators of bias or clarification of findings. Contains all elements of evaluation for specific system. Prevented use of phrases resembling “regular”, “acceptable”, or “good”. No bias or clarification for findings evident Incorporates all goal data Contains all elements of evaluation for specific system. Detailed data supplied. Prevented use of phrases resembling “regular”, “acceptable”, 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 threat elements for the consumer based mostly on the evaluation findings with no description or motive for choice of them. Failure to supply any potential or precise threat elements will end in zero factors for this criterion. Temporary description of 1 or two precise or potential threat elements for the consumer based mostly on evaluation findings with description or motive for choice of them. Restricted description of two precise or potential threat elements for the consumer based mostly on the evaluation findings with description or motive for choice of them. Complete, detailed description of two precise or potential threat elements for the consumer based mostly on the evaluation findings with description or motive for choice of them.
Factors: zero.5 Factors: 1 Factors: 1.5 Factors: 2
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