Posted: May 1st, 2022

Home Work essay

Title:

Documentation of downside based mostly evaluation of the top, ears, and eyes.

Objective of Project:

Studying the required elements of documenting an issue based mostly subjective and goal evaluation of a head, ears, and eyes. Establish irregular findings.

Course Competency:

Show bodily examination expertise of the top, ears, and eyes, nostril, mouth, neck, and regional lymphatics.

Directions:

Content material: Use of three sections:

· Subjective

· Goal

· Precise or potential threat elements for the consumer based mostly on the evaluation findings with description or motive for number of them.

Format:

· Commonplace American English (right grammar, punctuation, and so on.)

Sources:

Chapter three: SOAP Notes (subjective and goal solely)

Sullivan, D. (2018). Information to medical documentation. https://ebookcentral.proquest.com/lib/ras/element.motion?docID=5553403

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 potential factors

Ranges of Achievement

Standards

Rising

Competence

Proficiency

Mastery

Subjective

(four Pts)

Lacking elements akin to biographic knowledge, medicines, or allergy symptoms. Signs evaluation is incomplete. Might comprise goal knowledge.

Primary biographic knowledge offered. Medicines and allergy symptoms included. Signs evaluation incomplete. Missing element. No goal knowledge.

Primary biographic knowledge offered. Included checklist of medicines and allergy symptoms. Signs evaluation: PQRSTU accomplished. Missing element. No goal knowledge. Data is solely what “consumer” offered.

Primary biographic knowledge offered. Included checklist of medicines and allergy symptoms. Signs evaluation: PQRSTU accomplished. Detailed. No goal knowledge. Data is solely what “consumer” offered.

Factors: 1

Factors: 2

Factors: three

Factors: four

Goal

(four Pts)

Lacking elements of evaluation for explicit system. Might comprise subjective knowledge. Might have indicators of bias or clarification of findings. Might have included phrases akin to “regular”, “acceptable”, “okay”, and “good”.

Consists of all elements of evaluation for explicit system. Lacks element. Makes use of phrases akin to “regular”, “acceptable”, or “good”. Accommodates all goal info. Might have indicators of bias or clarification of findings.

Consists of all elements of evaluation for explicit system. Prevented use of phrases akin to “regular”, “acceptable”, or “good”. No bias or clarification for findings evident Accommodates all goal info

Consists of all elements of evaluation for explicit system. Detailed info offered. Prevented use of phrases akin to “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 Threat Components

(2 pts)

Lists one to 2 precise or potential threat elements for the consumer based mostly on the evaluation findings with no description or motive for number of them. Failure to offer 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 consumer based mostly on evaluation findings with description or motive for number of them.

Restricted description of two precise or potential threat elements for the consumer based mostly on the evaluation findings with description or motive for number of them.

Complete, detailed description of two precise or potential threat elements for the consumer based mostly on the evaluation findings with description or motive for number of them.

Factors: zero.5

Factors: 1

Factors: 1.5

Factors: 2

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