Title:
Documentation of downside primarily based analysis of the peripheral vascular system.
Operate of Undertaking:
Finding out the required components of documenting a difficulty primarily based subjective and objective analysis of peripheral vascular system. Decide irregular findings.
Course Competency:
Select acceptable bodily examination talents for the cardiovascular and peripheral vascular applications.
Instructions:
Content material materials: Use of three sections:
o Subjective
o Purpose
o Exact or potential risk components for the consumer based mostly totally on the analysis findings with no description or trigger for alternative of them.
Format:
• Customary American English (proper grammar, punctuation, and so forth.)
Sources:
Chapter 5: SOAP Notes: The subjective and objective portion solely
Sullivan, D. D. (2012). Data 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 online=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 online=eds-live >
Documentation Grading Rubric- 10 attainable elements
Ranges of Achievement
Requirements Rising Competence Proficiency Mastery
Subjective
(4 Pts) Missing components corresponding to biographic data, medication, or allergic reactions. Indicators analysis is incomplete. Would possibly embrace objective data.
Basic biographic data supplied. Medicines and allergic reactions included. Indicators analysis incomplete. Lacking ingredient. No objective data. Basic biographic data supplied. Included file of medicines and allergic reactions. Indicators analysis: PQRSTU achieved. Lacking ingredient. No objective data. Information is solely what “shopper” supplied. Basic biographic data supplied. Included file of medicines and allergic reactions. Indicators analysis: PQRSTU achieved. Detailed. No objective data. Information is solely what “shopper” supplied.
Components: 1 Components: 2 Components: three Components: 4
Purpose
(4 Pts) Missing components of analysis for express system. Would possibly embrace subjective data. May need indicators of bias or clarification of findings. May need included phrases corresponding to “common”, “acceptable”,
“okay”, and “good”.
Consists of all components of analysis for express system. Lacks ingredient. Makes use of phrases corresponding to “common”, “acceptable”, or “good”. Incorporates all objective information. May need indicators of bias or clarification of findings. Consists of all components of analysis for express system. Averted use of phrases corresponding to “common”, “acceptable”, or “good”. No bias or clarification for findings evident Incorporates all objective information Consists of all components of analysis for express system. Detailed information supplied. Averted use of phrases corresponding to “common”, “acceptable”, or “good”. No bias or clarification for findings evident. All objective information
Components: 1 Components: 2 Components: three Components: 4
Exact or Potential Risk Parts
(2 pts)
Lists one to 2 exact or potential risk components for the consumer based mostly totally on the analysis findings with no description or trigger for alternative of them. Failure to supply any potential or exact risk components will result in zero elements for this criterion. Transient description of 1 or two exact or potential risk components for the consumer based mostly totally on the analysis findings with description or trigger for alternative of them. Restricted description of two exact or potential risk components for the consumer based mostly totally on the analysis findings with description or trigger for alternative of them. Full, detailed description of two exact or potential risk components for the consumer based mostly totally on the analysis findings with description or trigger for alternative of them.
Components: zero.5 Components: 1 Components: 1.5 Components: 2
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