Title:
Documentation of disadvantage based analysis of the neurological system.
Purpose of Mission:
Finding out the required parts of documenting a problem based subjective and purpose analysis of neurological system. Decide irregular findings.
Course Competency:
Apply analysis strategies for the neurological and respiratory strategies.
Instructions:
Content material materials: Use of three sections:
o Subjective
o Purpose
o Exact or potential risk parts for the buyer based mostly totally on the analysis findings with description or motive for alternative of them.
Format:
• Customary American English (acceptable grammar, punctuation, and so forth.)
Sources:
Chapter 5: SOAP Notes: The subjective and purpose portion solely
Sullivan, D. D. (2012). Info 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 doable components
Ranges of Achievement
Requirements Rising Competence Proficiency Mastery
Subjective
(4 Pts) Missing parts resembling biographic information, medication, or allergic reactions. Indicators analysis is incomplete. May comprise purpose information.
Major biographic information provided. Medicines and allergic reactions included. Indicators analysis incomplete. Lacking factor. No purpose information. Major biographic information provided. Included report of medicines and allergic reactions. Indicators analysis: PQRSTU achieved. Lacking factor. No purpose information. Data is solely what “shopper” provided. Major biographic information provided. Included report of medicines and allergic reactions. Indicators analysis: PQRSTU achieved. Detailed. No purpose information. Data is solely what “shopper” provided.
Elements: 1 Elements: 2 Elements: three Elements:4
Purpose
(4 Pts) Missing parts of analysis for particular system. May comprise subjective information. May have indicators of bias or clarification of findings. May have included phrases resembling “common”, “acceptable”,
“okay”, and “good”.
Accommodates all parts of analysis for particular system. Lacks factor. Makes use of phrases resembling “common”, “acceptable”, or “good”. Incorporates all purpose information. May have indicators of bias or clarification of findings. Accommodates all parts of analysis for particular system. Prevented use of phrases resembling “common”, “acceptable”, or “good”. No bias or clarification for findings evident Incorporates all purpose information Accommodates all parts of analysis for particular system. Detailed information provided. Prevented use of phrases resembling “common”, “acceptable”, or “good”. No bias or clarification for findings evident. All purpose information
Elements: 1 Elements: 2 Elements: three Elements: 4
Exact or Potential Hazard Parts
(2 pts)
Lists one to 2 exact or potential risk parts for the buyer based mostly totally on the analysis findings with no description or motive for alternative of them. Failure to provide any potential or exact risk parts will finish in zero components for this criterion. Momentary description of 1 or two exact or potential risk parts for the buyer based mostly totally on analysis findings with description or motive for alternative of them. Restricted description of two exact or potential risk parts for the buyer based mostly totally on the analysis findings with description or motive for alternative of them. Full, detailed description of two exact or potential risk parts for the buyer based mostly totally on the analysis findings with description or motive for alternative of them.
Elements: zero.5 Elements: 1 Elements: 1.5 Elements: 2
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