Title:
Documentation of the entire head to toe bodily evaluation.
Goal of Task:
To display the power to doc the findings of an goal head to toe evaluation and establish irregular findings.
Course Competency:
Show bodily examination abilities of the pores and skin, hair, nails, and musculoskeletal system.
Prioritize applicable evaluation strategies for the gastrointestinal, breasts, and genitourinary techniques.
Show bodily examination abilities of the top, ears, and eyes, nostril, mouth, neck, and regional lymphatics.
Apply evaluation strategies for the neurological and respiratory techniques.
Choose applicable bodily examination abilities for the cardiovascular and peripheral vascular techniques.
Directions:
Content material:
· Goal findings together with quick descriptive paragraph of findings for every part.
· Precise or potential danger components for the shopper based mostly on the evaluation findings with description or cause for choice of them.
Format:
· Commonplace 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&website=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&website=eds-live
Documentation Grading Rubric- 20 doable factors
Ranges of Achievement
Standards
Rising
Competence
Proficiency
Mastery
Goal
(16 Pts)
Lacking parts of evaluation for explicit system. Could include subjective knowledge. Could have indicators of bias or rationalization of findings. Could have included phrases similar to “regular”, “applicable”, “okay”, and “good”.
Failure to supply any goal knowledge will lead to zero factors for this criterion.
Contains all parts of evaluation for explicit system. Lacks element. Makes use of phrases similar to “regular”, “applicable”, or “good”. Comprises all goal info. Could have indicators of bias or rationalization of findings.
Contains all parts of evaluation for explicit system. Prevented use of phrases similar to “regular”, “applicable”, or “good”. No bias or rationalization for findings evident Comprises all goal info
Contains all parts of evaluation for explicit system. Detailed info offered. Prevented use of phrases similar to “regular”, “applicable”, or “good”. No bias or rationalization for findings evident. All goal info
Factors: 11
Factors: 14
Factors: 15
Factors: 16
Precise or Potential Danger Components (four Pts)
Lists one to 2 precise or potential danger components for the shopper based mostly on the evaluation findings with no description or cause for choice of them. Failure to supply any potential or precise danger components will lead to zero factors for this criterion.
Transient description of 1 or two precise or potential danger components for the shopper based mostly on the evaluation findings with description or cause for choice of them.
Restricted description of two precise or potential danger components for the shopper based mostly on the evaluation findings with description or cause for choice of them.
Complete, detailed description of two precise or potential danger components for the shopper based mostly on the evaluation findings with description or cause for choice of them.
Factors: 1
Factors: 2
Factors: three
Factors: four
Factors: 12
Factors: 16
Factors: 18
Factors: 20
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