Title:
Documentation of the entire head to toe bodily evaluation.
Objective of Project:
To reveal the power to doc the findings of an goal head to toe evaluation and establish irregular findings.
Course Competency:
Display bodily examination abilities of the pores and skin, hair, nails, and musculoskeletal system.
Prioritize applicable evaluation methods for the gastrointestinal, breasts, and genitourinary methods.
Display bodily examination abilities of the top, ears, and eyes, nostril, mouth, neck, and regional lymphatics.
Apply evaluation methods for the neurological and respiratory methods.
Choose applicable bodily examination abilities for the cardiovascular and peripheral vascular methods.
Directions:
Content material:
• Goal findings together with quick descriptive paragraph of findings for every part.
• Precise or potential threat elements for the consumer based mostly on the evaluation findings with description or motive for choice of them.
Format:
• Normal American English (appropriate grammar, punctuation, and so forth.)
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- 20 doable factors
Ranges of Achievement
Standards Rising Competence Proficiency Mastery
Goal
(16 Pts) Lacking parts of evaluation for explicit system. Could comprise subjective knowledge. Could have indicators of bias or rationalization of findings. Could have included phrases similar to “regular”, “applicable”,
“okay”, and “good”.
Failure to offer any goal knowledge will end in zero factors for this criterion. Consists of all parts of evaluation for explicit system. Lacks element. Makes use of phrases similar to “regular”, “applicable”, or “good”. Comprises all goal data. Could have indicators of bias or rationalization of findings. Consists of 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 data Consists of all parts of evaluation for explicit system. Detailed data offered. Prevented use of phrases similar to “regular”, “applicable”, or “good”. No bias or rationalization for findings evident. All goal data
Factors: 11 Factors: 14 Factors: 15 Factors: 16
Precise or Potential Danger Components (four 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 offer 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 the 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: 1 Factors: 2 Factors: three Factors: four
Factors: 12 Factors: 16 Factors: 18 Factors: 20
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