Title:
Documentation of drawback primarily based Assessment of the peripheral vascular system.
Goal of Assignment:
Studying the required elements of documenting an issue primarily based subjective and goal Assessment of peripheral vascular system. Determine irregular findings.
Course Competency:
Choose applicable bodily examination abilities for the cardiovascular and peripheral vascular methods.
Directions:
Content material: Use of three sections:
o Subjective
o Goal
o Precise or potential threat elements for the shopper primarily based on the Assessment findings with no description or motive for choice of them.
Format:
• Normal American English (right grammar, punctuation, and so on.)
Sources:
Chapter 5: SOAP Notes: The subjective and goal portion solely
Sullivan, D. D. (2012). Information 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- 10 attainable factors
Ranges of Achievement
Standards Rising Competence Proficiency Mastery
Subjective
(four Pts) Lacking elements equivalent to biographic information, drugs, or allergic reactions. Signs Assessment is incomplete. Could comprise goal information.
Fundamental biographic information supplied. Drugs and allergic reactions included. Signs Assessment incomplete. Missing element. No goal information. Fundamental biographic information supplied. Included listing of medicines and allergic reactions. Signs Assessment: PQRSTU accomplished. Missing element. No goal information. Data is solely what “shopper” supplied. Fundamental biographic information supplied. Included listing of medicines and allergic reactions. Signs Assessment: PQRSTU accomplished. Detailed. No goal information. Data is solely what “shopper” supplied.
Factors: 1 Factors: 2 Factors: three Factors: four
Goal
(four Pts) Lacking elements of Assessment for specific system. Could comprise subjective information. Could have indicators of bias or clarification of findings. Could have included phrases equivalent to “regular”, “applicable”,
“okay”, and “good”.
Consists of all elements of Assessment for specific system. Lacks element. Makes use of phrases equivalent to “regular”, “applicable”, or “good”. Comprises all goal info. Could have indicators of bias or clarification of findings. Consists of all elements of Assessment for specific system. Averted use of phrases equivalent to “regular”, “applicable”, or “good”. No bias or clarification for findings evident Comprises all goal info Consists of all elements of Assessment for specific system. Detailed info supplied. Averted use of phrases equivalent to “regular”, “applicable”, or “good”. No bias or clarification for findings evident. All goal info
Factors: 1 Factors: 2 Factors: three Factors: four
Precise or Potential Threat Components
(2 pts)
Lists one to 2 precise or potential threat elements for the shopper primarily based on the Assessment findings with no description or motive for choice of them. Failure to supply any potential or precise threat elements will lead to zero factors for this criterion. Temporary description of 1 or two precise or potential threat elements for the shopper primarily based on the Assessment findings with description or motive for choice of them. Restricted description of two precise or potential threat elements for the shopper primarily based on the Assessment findings with description or motive for choice of them. Complete, detailed description of two precise or potential threat elements for the shopper primarily based on the Assessment findings with description or motive for choice of them.
Factors: zero.5 Factors: 1 Factors: 1.5 Factors: 2
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