Posted: May 1st, 2022

Documentation of the complete head to toe physical assessment

– Documentation of Full Head to Toe Bodily Evaluation

You accomplished your full head-to-toe evaluation expertise demonstration final week and now will doc your outcomes. Proceed to doc solely the target findings for this part with out bias or clarification. Keep in mind for those who can’t really feel one thing then it’s “nonpalpable,” for those who can’t hear one thing simply state they weren’t heard akin to no bowel sounds heard (except you listened for the complete 5 minutes which we wouldn’t need to do for our functions – then you possibly can doc absent bowel sounds). Be descriptive if vital however on the similar time be transient. Don’t write a e book!

Full Head-to-Toe Bodily Evaluation Project

Title:
Documentation of the whole head to toe bodily evaluation.

Objective of Project:
To exhibit the power to doc the findings of an goal head to toe evaluation and establish irregular findings.

Course Competency:
Reveal bodily examination expertise of the pores and skin, hair, nails, and musculoskeletal system.
Prioritize applicable evaluation strategies for the gastrointestinal, breasts, and genitourinary methods.
Reveal bodily examination expertise of the pinnacle, ears, and eyes, nostril, mouth, neck, and regional lymphatics.
Apply evaluation strategies for the neurological and respiratory methods.
Choose applicable bodily examination expertise for the cardiovascular and peripheral vascular methods.

Directions:

Content material:
• Use of three sections: Subjective, Goal, and Irregular Findings
• Brief descriptive paragraph of findings for every part, together with strengths and weaknesses.

Format:
• Customary American English (right grammar, punctuation, and many others.)

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&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- 20 attainable factors
Ranges of Achievement
Standards Rising Competence Proficiency Mastery
Goal
(12 Pts) Lacking elements of evaluation for specific system. Could include subjective information. Could have indicators of bias or clarification of findings. Could have included phrases akin to “regular”, “applicable”,
“okay”, and “good”.
Failure to offer any goal information will end in zero factors for this standards. Contains all elements of evaluation for specific system. Lacks element. Makes use of phrases akin to “regular”, “applicable”, or “good”. Accommodates all goal info. Could have indicators of bias or clarification of findings. Contains all elements of evaluation for specific system. Prevented use of phrases akin to “regular”, “applicable”, or “good”. No bias or clarification for findings evident Accommodates all goal info Contains all elements of evaluation for specific system. Detailed info supplied. Prevented use of phrases akin to “regular”, “applicable”, or “good”. No bias or clarification for findings evident. All goal info
Factors: 9 Factors: 12 Factors: 13.5 Factors: 15
Power and Weak spot
(four Pts) Lists one energy and one weak point with no description or purpose for collection of them. Failure to offer each one energy and weak point will end in zero factors for this standards. Supplies transient description of 1 energy and one weak point with no purpose for identification of the energy and weak point. Supplies description of 1 energy and one weak point famous on evaluation. Provides purpose for identification of the energy and weak point. Detailed description of 1 energy and one weak point famous throughout evaluation. Detailed purpose supplied for figuring out the energy and weak point.
Factors: 1.eight Factors: 2.four Factors: 2.7 Factors: three
Spelling and Grammar
(four Pt)
Six or extra spelling or grammar errors. Detracts from the readability of the submission. Not more than 5 spelling or grammar errors, minimally detracts from the readability of the submission. Not more than three spelling or grammar errors. Doesn’t detract from the readability of the submission. No spelling or grammar errors.
Factors: 1.2 Factors: 1.6 Factors: 1.eight Factors: 2
Factors: 12 Factors: 16 Factors: 18 Factors: 20