Title:
Documentation of problem based assessment of the head, ears, and eyes.
Purpose of Assignment:
Learning the required components of documenting a problem based subjective and objective assessment of a head, ears, and eyes. Identify abnormal findings.
Course Competency:
Demonstrate physical examination skills of the head, ears, and eyes, nose, mouth, neck, and regional lymphatics.
Instructions:
Content: Use of three sections:
o Subjective
o Objective
o Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.
Format:
• Standard American English (correct grammar, punctuation, etc.)
Resources:
Chapter 3: SOAP Notes (subjective and objective only)
Sullivan, D. (2018). Guide to clinical documentation. https://ebookcentral.proquest.com/lib/ras/detail.action?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&site=eds-live
Documentation Grading Rubric- 10 possible points
Levels of Achievement
Criteria Emerging Competence Proficiency Mastery
Subjective
(4 Pts) Missing components such as biographic data, medications, or allergies. Symptoms analysis is incomplete. May contain objective data.
Basic biographic data provided. Medications and allergies included. Symptoms analysis incomplete. Lacking detail. No objective data. Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Lacking detail. No objective data. Information is solely what “client” provided. Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Detailed. No objective data. Information is solely what “client” provided.
Points: 1 Points: 2 Points: 3 Points: 4
Objective
(4 Pts) Missing components of assessment for particular system. May contain subjective data. May have signs of bias or explanation of findings. May have included words such as “normal”, “appropriate”,
“okay”, and “good”.
Includes all components of assessment for particular system. Lacks detail. Uses words such as “normal”, “appropriate”, or “good”. Contains all objective information. May have signs of bias or explanation of findings. Includes all components of assessment for particular system. Avoided use of words such as “normal”, “appropriate”, or “good”. No bias or explanation for findings evident Contains all objective information Includes all components of assessment for particular system. Detailed information provided. Avoided use of words such as “normal”, “appropriate”, or “good”. No bias or explanation for findings evident. All objective information
Points: 1 Points: 2 Points: 3 Points: 4
Actual or Potential Risk Factors
(2 pts)
Lists one to two actual or potential risk factors for the client based on the assessment findings with no description or reason for selection of them. Failure to provide any potential or actual risk factors will result in zero points for this criterion. Brief description of one or two actual or potential risk factors for the client based on assessment findings with description or reason for selection of them. Limited description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them. Comprehensive, detailed description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.
Points: 0.5 Points: 1 Points: 1.5 Points: 2
