Module 11 Lab Assignment – Documentation of Complete Head to Toe Physical Assessment
Module 11 Lab Assignment – Documentation of Complete Head to Toe Physical Assessment
Prime of Kind
Backside of Kind
Module 11 Content material
1.
Prime of Kind
You accomplished your full head-to-toe Assessment expertise demonstration final week and now will doc your outcomes. Proceed to doc solely the target findings for this part with out bias or rationalization. Keep in mind if you happen to can’t really feel one thing then it’s “nonpalpable,” if you happen to can’t hear one thing simply state they weren’t heard equivalent to no bowel sounds heard (until you listened for the total 5 minutes which we wouldn’t need to do for our functions – then you can doc absent bowel sounds). Be descriptive if mandatory however on the similar time be transient.
Complete Head-to-Toe Physical Assessment Assignment.docx
Submit your accomplished project by following the instructions linked under. Please examine the Course Calendar for particular due dates.
Backside of Kind
Title:
Documentation of the entire head to toe bodily Assessment.
Function of Assignment:
To show the power to doc the findings of an goal head to toe Assessment and determine irregular findings.
Course Competency:
Show bodily examination expertise of the pores and skin, hair, nails, and musculoskeletal system.
Prioritize applicable Assessment methods for the gastrointestinal, breasts, and genitourinary methods.
Show bodily examination expertise of the pinnacle, ears, and eyes, nostril, mouth, neck, and regional lymphatics.
Apply Assessment methods for the neurological and respiratory methods.
Choose applicable bodily examination expertise for the cardiovascular and peripheral vascular methods.
Directions:
Content material:
· Goal findings together with quick descriptive paragraph of findings for every part.
· Precise or potential threat elements for the consumer based mostly on the Assessment findings with description or purpose for choice of them.
Format:
· Commonplace American English (right grammar, punctuation, and so forth.)
Assets:
Chapter 5: SOAP Notes: The subjective and goal portion solely
Sullivan, D. D. (2012). Information to scientific 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- 20 attainable factors
Ranges of Achievement
Standards
Rising
Competence
Proficiency
Mastery
Goal
(16 Pts)
Lacking parts of Assessment for specific system. Could include subjective information. Could have indicators of bias or rationalization of findings. Could have included phrases equivalent to “regular”, “applicable”, “okay”, and “good”.
Failure to present any goal information will end in zero factors for this criterion.
Consists of all parts of Assessment for specific system. Lacks element. Makes use of phrases equivalent to “regular”, “applicable”, or “good”. Comprises all goal data. Could have indicators of bias or rationalization of findings.
Consists of all parts of Assessment for specific system. Prevented use of phrases equivalent to “regular”, “applicable”, or “good”. No bias or rationalization for findings evident Comprises all goal data
Consists of all parts of Assessment for specific system. Detailed data offered. Prevented use of phrases equivalent to “regular”, “applicable”, or “good”. No bias or rationalization for findings evident. All goal data
Factors: 11
Factors: 14
Factors: 15
Factors: 16
Precise or Potential Threat Elements (four Pts)
Lists one to two precise or potential threat elements for the consumer based mostly on the Assessment findings with no description or purpose for choice of them. Failure to present any potential or precise threat elements will end in zero factors for this criterion.
Transient description of one or two precise or potential threat elements for the consumer based mostly on the Assessment findings with description or purpose for choice of them.
Restricted description of two precise or potential threat elements for the consumer based mostly on the Assessment findings with description or purpose for choice of them.
Complete, detailed description of two precise or potential threat elements for the consumer based mostly on the Assessment findings with description or purpose for choice of them.
Factors: 1
Factors: 2
Factors: three
Factors: four
Factors: 12
Factors: 16
Factors: 18
Factors: 20
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Module 11 Lab Assignment – Complete Head to Toe Physical Assessment Documentation
Module 11 Lab Assignment – Complete Head to Toe Physical Assessment Documentation
Glorious Kind
Backside of the Kind
Module Eleven Content material
1.
Glorious Kind
You completed your complete head-to-toe Assessment expertise demonstration final week and can now doc your findings. For this section, proceed to doc merely the target findings with out bias or interpretation. Keep in mind if you happen to can’t really feel one thing then it’s “nonpalpable,” if you happen to can’t hear one thing simply state they weren’t heard equivalent to no bowel sounds heard (until you listened for the total 5 minutes which we wouldn’t need to do for our functions – then you can doc absent bowel sounds). Be descriptive if mandatory however on the
