Title:
Documentation of downside primarily based evaluation of the pinnacle, ears, and eyes.
Objective of Task:
Studying the required elements of documenting an issue primarily based subjective and goal evaluation of a head, ears, and eyes. Determine irregular findings.
Course Competency:
Show bodily examination expertise of the pinnacle, ears, and eyes, nostril, mouth, neck, and regional lymphatics.
Directions:
Content material: Use of three sections:
o Subjective
o Goal
o Precise or potential threat components for the shopper primarily based on the evaluation findings with description or purpose for choice of them.
Format:
• Commonplace American English (appropriate grammar, punctuation, and so forth.)
Sources:
Chapter three: SOAP Notes (subjective and goal solely)
Sullivan, D. (2018). Information to scientific 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&website=eds-live
Documentation Grading Rubric- 10 doable factors
Ranges of Achievement
Standards Rising Competence Proficiency Mastery
Subjective
(four Pts) Lacking elements corresponding to biographic knowledge, drugs, or allergy symptoms. Signs evaluation is incomplete. Might include goal knowledge.
Fundamental biographic knowledge supplied. Drugs and allergy symptoms included. Signs evaluation incomplete. Missing element. No goal knowledge. Fundamental biographic knowledge supplied. Included checklist of medicines and allergy symptoms. Signs evaluation: PQRSTU accomplished. Missing element. No goal knowledge. Info is solely what “shopper” supplied. Fundamental biographic knowledge supplied. Included checklist of medicines and allergy symptoms. Signs evaluation: PQRSTU accomplished. Detailed. No goal knowledge. Info is solely what “shopper” supplied.
Factors: 1 Factors: 2 Factors: three Factors: four
Goal
(four Pts) Lacking elements of evaluation for specific system. Might include subjective knowledge. Might have indicators of bias or clarification of findings. Might have included phrases corresponding to “regular”, “applicable”,
“okay”, and “good”.
Consists of all elements of evaluation for specific system. Lacks element. Makes use of phrases corresponding to “regular”, “applicable”, or “good”. Accommodates all goal info. Might have indicators of bias or clarification of findings. Consists of all elements of evaluation for specific system. Prevented use of phrases corresponding to “regular”, “applicable”, or “good”. No bias or clarification for findings evident Accommodates all goal info Consists of all elements of evaluation for specific system. Detailed info supplied. Prevented use of phrases corresponding to “regular”, “applicable”, or “good”. No bias or clarification for findings evident. All goal info
Factors: 1 Factors: 2 Factors: three Factors: four
Precise or Potential Danger Elements
(2 pts)
Lists one to 2 precise or potential threat components for the shopper primarily based on the evaluation findings with no description or purpose for choice of them. Failure to supply any potential or precise threat components will lead to zero factors for this criterion. Transient description of 1 or two precise or potential threat components for the shopper primarily based on evaluation findings with description or purpose for choice of them. Restricted description of two precise or potential threat components 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 threat components 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
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