Title:
Documentation of drawback primarily based Assessment of the neurological system.
Function of Task:
Studying the required elements of documenting an issue primarily based subjective and goal Assessment of neurological system. Establish irregular findings.
Course Competency:
Apply Assessment methods for the neurological and respiratory programs.
Directions:
Content material: Use of three sections:
o Subjective
o Goal
o Precise or potential threat components for the shopper primarily based on the Assessment findings with description or purpose for choice of them.
Format:
• Customary American English (appropriate grammar, punctuation, and many others.)
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 doable factors
Ranges of Achievement
Standards Rising Competence Proficiency Mastery
Subjective
(four Pts) Lacking elements reminiscent of biographic information, medicines, or allergic reactions. Signs Assessment is incomplete. Could comprise goal information.
Fundamental biographic information supplied. Medicines 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 reminiscent of “regular”, “acceptable”,
“okay”, and “good”.
Contains all elements of Assessment for specific system. Lacks element. Makes use of phrases reminiscent of “regular”, “acceptable”, or “good”. Accommodates all goal info. Could have indicators of bias or clarification of findings. Contains all elements of Assessment for specific system. Prevented use of phrases reminiscent of “regular”, “acceptable”, or “good”. No bias or clarification for findings evident Accommodates all goal info Contains all elements of Assessment for specific system. Detailed info supplied. Prevented use of phrases reminiscent of “regular”, “acceptable”, or “good”. No bias or clarification for findings evident. All goal info
Factors: 1 Factors: 2 Factors: three Factors: four
Precise or Potential Danger Components
(2 pts)
Lists one to 2 precise or potential threat components for the shopper primarily based on the Assessment findings with no description or purpose for choice of them. Failure to supply any potential or precise threat components will lead to zero factors for this criterion. Transient description of 1 or two precise or potential threat components for the shopper primarily based on Assessment findings with description or purpose for choice of them. Restricted description of two precise or potential threat components for the shopper primarily based on the Assessment findings with description or purpose for choice of them. Complete, detailed description of two precise or potential threat components for the shopper primarily based on the Assessment findings with description or purpose for choice of them.
Factors: zero.5 Factors: 1 Factors: 1.5 Factors: 2
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