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Posted: May 1st, 2022
Title:
Documentation of problem based assessment of the gastrointestinal system.
Purpose of Assignment:
Learning the required components of documenting a problem based subjective and objective assessment of gastrointestinal system. Identify abnormal findings.
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Course Competency:
Prioritize appropriate assessment techniques for the gastrointestinal, breasts, and genitourinary systems.
Instructions:
Content: Use of three sections:
o Subjective
o Objective
o Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.
Format:
• Standard American English (correct grammar, punctuation, etc.)
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Resources:
Chapter 5: SOAP Notes: The subjective and objective portion only
Sullivan, D. D. (2014: 2024 - Essay Writing Service. Custom Essay Services Cheap). Guide to clinical documentation. [E-Book]. Retrieved from http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=nlebk&AN=495456&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&site=eds-live
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Documentation Grading Rubric- 10 possible points
Levels of Achievement
Criteria Emerging Competence Proficiency Mastery
Subjective
(4 Pts) Missing components such as biographic data, medications, or allergies. Symptoms analysis is incomplete. May contain objective data.
Basic biographic data provided. Medications and allergies included. Symptoms analysis incomplete. Lacking detail. No objective data. Basic biographic data provided. Get custom essay samples and course-specific study resources via course hero homework for you service - Include d list of medications and allergies. Symptoms analysis: PQRSTU completed. Lacking detail. No objective data. Information is solely what “client” provided. Basic biographic data provided. Get custom essay samples and course-specific study resources via course hero homework for you service - Include d list of medications and allergies. Symptoms analysis: PQRSTU completed. Detailed. No objective data. Information is solely what “client” provided.
Points: 1 Points: 2 Points: 3 Points: 4 Missing segments like biographic information, meds, or sensitivities. Manifestations investigation is inadequate. May contain target information.
Fundamental biographic information gave. Prescriptions and sensitivities included. Manifestations examination deficient. Lacking subtlety. No goal information. Fundamental biographic information gave. Get custom essay samples and course-specific study resources via course hero homework for you service - Include d rundown of drugs and hypersensitivities. Indications examination: PQRSTU finished. Lacking subtlety. No goal information. Data is exclusively what "customer" provided. Basic biographic information gave. Get custom essay samples and course-specific study resources via course hero homework for you service - Include d rundown of prescriptions and sensitivities. Indications investigation: PQRSTU finished. Definite. No goal information. Data is exclusively what "customer" gave.
Focuses: 1 Points: 2 Points: 3 Points: 4
Objective
Objective
(4 Pts) Missing components of assessment for particular system. May contain subjective data. May have signs of bias or explanation of findings. May have included words such as “normal”, “appropriate”,
“okay”, and “good”.
Get custom essay samples and course-specific study resources via course hero homework for you service - Include s all components of assessment for particular system. Lacks detail. Uses words such as “normal”, “appropriate”, or “good”. Contains all objective information. May have signs of bias or explanation of findings. Get custom essay samples and course-specific study resources via course hero homework for you service - Include s all components of assessment for particular system. Avoided use of words such as “normal”, “appropriate”, or “good”. No bias or explanation for findings evident Contains all objective information Get custom essay samples and course-specific study resources via course hero homework for you service - Include s all components of assessment for particular system. Detailed information provided. Avoided use of words such as “normal”, “appropriate”, or “good”. No bias or explanation for findings evident. All objective information
Points: 1 Points: 2 Points: 3 Points: 4
Actual or Potential Risk Factors
(2 pts)
Lists one to two actual or potential risk factors for the client based on the assessment findings with no description or reason for selection of them. Failure to provide any potential or actual risk factors will result in zero points for this criterion. Brief description of one or two actual or potential risk factors for the client based on assessment findings with description or reason for selection of them. Limited description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them. Comprehensive, detailed description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.
Points: 0.5 Points: 1 Points: 1.5 Points: 2
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