Title:
Documentation of the whole head to toe bodily analysis.
Aim of Activity:
To show the facility to doc the findings of an objective head to toe analysis and set up irregular findings.
Course Competency:
Present bodily examination skills of the pores and pores and skin, hair, nails, and musculoskeletal system.
Prioritize relevant analysis methods for the gastrointestinal, breasts, and genitourinary strategies.
Present bodily examination skills of the highest, ears, and eyes, nostril, mouth, neck, and regional lymphatics.
Apply analysis methods for the neurological and respiratory strategies.
Select relevant bodily examination skills for the cardiovascular and peripheral vascular strategies.
Instructions:
Content material materials:
· Aim findings along with fast descriptive paragraph of findings for each half.
· Exact or potential hazard parts for the patron primarily based totally on the analysis findings with description or trigger for selection of them.
Format:
· Commonplace American English (acceptable grammar, punctuation, and so forth.)
Sources:
Chapter 5: SOAP Notes: The subjective and objective 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&web site=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&web site=eds-live
Documentation Grading Rubric- 20 doable components
Ranges of Achievement
Requirements
Rising
Competence
Proficiency
Mastery
Aim
(16 Pts)
Missing elements of analysis for specific system. Might embrace subjective data. Might have indicators of bias or rationalization of findings. Might have included phrases much like “common”, “relevant”, “okay”, and “good”.
Failure to produce any objective data will result in zero components for this criterion.
Accommodates all elements of analysis for specific system. Lacks factor. Makes use of phrases much like “common”, “relevant”, or “good”. Includes all objective information. Might have indicators of bias or rationalization of findings.
Accommodates all elements of analysis for specific system. Prevented use of phrases much like “common”, “relevant”, or “good”. No bias or rationalization for findings evident Includes all objective information
Accommodates all elements of analysis for specific system. Detailed information supplied. Prevented use of phrases much like “common”, “relevant”, or “good”. No bias or rationalization for findings evident. All objective information
Components: 11
Components: 14
Components: 15
Components: 16
Exact or Potential Hazard Parts (4 Pts)
Lists one to 2 exact or potential hazard parts for the patron primarily based totally on the analysis findings with no description or trigger for selection of them. Failure to produce any potential or exact hazard parts will result in zero components for this criterion.
Transient description of 1 or two exact or potential hazard parts for the patron primarily based totally on the analysis findings with description or trigger for selection of them.
Restricted description of two exact or potential hazard parts for the patron primarily based totally on the analysis findings with description or trigger for selection of them.
Full, detailed description of two exact or potential hazard parts for the patron primarily based totally on the analysis findings with description or trigger for selection of them.
Components: 1
Components: 2
Components: three
Components: 4
Components: 12
Components: 16
Components: 18
Components: 20
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