Title:
Documentation of drawback based mostly evaluation of the nostril, throat, neck, and regional lymphatics.
Objective of Task:
Studying the required parts of documenting an issue based mostly subjective and goal evaluation of nostril, throat, neck, and regional lymphatics. Establish irregular findings.
Course Competency:
Display bodily examination abilities 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 based mostly on the evaluation findings with description or cause for collection of them.
Format:
• Commonplace American English (right grammar, punctuation, and so on.)
Assets:
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- 10 doable factors
Ranges of Achievement
Standards Rising Competence Proficiency Mastery
Subjective
(four Pts) Lacking parts equivalent to biographic knowledge, drugs, or allergy symptoms. Signs evaluation is incomplete. Could include goal knowledge.
Primary biographic knowledge offered. Drugs and allergy symptoms included. Signs evaluation incomplete. Missing element. No goal knowledge. Primary biographic knowledge offered. Included record of medicines and allergy symptoms. Signs evaluation: PQRSTU accomplished. Missing element. No goal knowledge. Data is solely what “shopper” offered. Primary biographic knowledge offered. Included record of medicines and allergy symptoms. Signs evaluation: PQRSTU accomplished. Detailed. No goal knowledge. 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 include subjective knowledge. Could have indicators of bias or clarification of findings. Could have included phrases equivalent to “regular”, “acceptable”,
“okay”, and “good”.
Contains all parts of evaluation for explicit system. Lacks element. Makes use of phrases equivalent to “regular”, “acceptable”, or “good”. Comprises all goal info. Could have indicators of bias or clarification of findings. Contains all parts of evaluation for explicit system. Averted use of phrases equivalent to “regular”, “acceptable”, or “good”. No bias or clarification for findings evident Comprises all goal info Contains all parts of evaluation for explicit system. Detailed info offered. Averted use of phrases equivalent to “regular”, “acceptable”, or “good”. No bias or clarification for findings evident. All goal info
Factors: 1 Factors: 2 Factors: three Factors: four
Precise or Potential Threat Components
(2 pts)
Lists one to 2 precise or potential threat components for the shopper based mostly on the evaluation findings with no description or cause for collection of them. Failure to offer any potential or precise threat components will end in zero factors for this criterion. Temporary description of 1 or two precise or potential threat components for the shopper based mostly on evaluation findings with description or cause for collection of them. Restricted description of two precise or potential threat components for the shopper based mostly on the evaluation findings with description or cause for collection of them. Complete, detailed description of two precise or potential threat components for the shopper based mostly 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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