Title:
Documentation of drawback based mostly Assessment of the gastrointestinal system.
Function of Assignment:
Studying the required elements of documenting an issue based mostly subjective and goal Assessment of gastrointestinal system. Determine irregular findings.
Course Competency:
Prioritize acceptable Assessment strategies for the gastrointestinal, breasts, and genitourinary methods.
Directions:
Content material: Use of three sections:
o Subjective
o Goal
o Precise or potential danger elements for the consumer based mostly on the Assessment findings with description or motive for choice of them.
Format:
• Normal American English (appropriate 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- 10 doable factors
Ranges of Achievement
Standards Rising Competence Proficiency Mastery
Subjective
(4 Pts) Lacking elements resembling biographic knowledge, medicines, or allergic reactions. Signs Assessment is incomplete. Might comprise goal knowledge.
Fundamental biographic knowledge offered. Drugs and allergic reactions included. Signs Assessment incomplete. Missing element. No goal knowledge. Fundamental biographic knowledge offered. Included listing of medicines and allergic reactions. Signs Assessment: PQRSTU accomplished. Missing element. No goal knowledge. Info is solely what “consumer” offered. Fundamental biographic knowledge offered. Included listing of medicines and allergic reactions. Signs Assessment: PQRSTU accomplished. Detailed. No goal knowledge. Info is solely what “consumer” offered.
Factors: 1 Factors: 2 Factors: three Factors: 4 Lacking segments like biographic data, meds, or sensitivities. Manifestations investigation is insufficient. Might comprise goal data.
Elementary biographic data gave. Prescriptions and sensitivities included. Manifestations examination poor. Missing subtlety. No aim data. Elementary biographic data gave. Included rundown of medicine and hypersensitivities. Indications examination: PQRSTU completed. Missing subtlety. No aim data. Knowledge is completely what “buyer” offered. Fundamental biographic data gave. Included rundown of prescriptions and sensitivities. Indications investigation: PQRSTU completed. Particular. No aim data. Knowledge is completely what “buyer” gave.
Focuses: 1 Factors: 2 Factors: three Factors: 4
Goal
Goal
(4 Pts) Lacking elements of Assessment for explicit system. Might comprise subjective knowledge. Might have indicators of bias or rationalization of findings. Might have included phrases resembling “regular”, “acceptable”,
“okay”, and “good”.
Consists of all elements of Assessment for explicit system. Lacks element. Makes use of phrases resembling “regular”, “acceptable”, or “good”. Incorporates all goal data. Might have indicators of bias or rationalization of findings. Consists of all elements of Assessment for explicit system. Prevented use of phrases resembling “regular”, “acceptable”, or “good”. No bias or rationalization for findings evident Incorporates all goal data Consists of all elements of Assessment for explicit system. Detailed data offered. Prevented use of phrases resembling “regular”, “acceptable”, or “good”. No bias or rationalization for findings evident. All goal data
Factors: 1 Factors: 2 Factors: three Factors: 4
Precise or Potential Danger Elements
(2 pts)
Lists one to 2 precise or potential danger elements for the consumer based mostly on the Assessment findings with no description or motive for choice of them. Failure to supply any potential or precise danger elements will end in zero factors for this criterion. Transient description of one or two precise or potential danger elements for the consumer based mostly on Assessment findings with description or motive for choice of them. Restricted description of two precise or potential danger elements for the consumer based mostly on the Assessment findings with description or motive for choice of them. Complete, detailed description of two precise or potential danger elements for the consumer based mostly on the Assessment findings with description or motive for choice of them.
Factors: zero.5 Factors: 1 Factors: 1.5 Factors: 2
