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Posted: May 1st, 2022
Title:
Documentation of drawback based mostly evaluation of the peripheral vascular system.
Function of Project:
Studying the required elements of documenting an issue based mostly subjective and goal evaluation of peripheral vascular system. Determine irregular findings.
Course Competency:
Choose acceptable bodily examination abilities for the cardiovascular and peripheral vascular programs.
Directions:
Content material: Use of three sections:
o Subjective
o Goal
o Precise or potential threat elements for the shopper based mostly on the evaluation findings with no description or cause for choice of them.
Format:
• Customary American English (right grammar, punctuation, and so forth.)
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 attainable factors
Ranges of Achievement
Standards Rising Competence Proficiency Mastery
Subjective
(four Pts) Lacking elements comparable to biographic knowledge, drugs, or allergic reactions. Signs evaluation is incomplete. Might include goal knowledge.
Fundamental biographic knowledge offered. Medicines and allergic reactions included. Signs evaluation incomplete. Missing element. No goal knowledge. Fundamental biographic knowledge offered. Included record of medicines and allergic reactions. Signs evaluation: PQRSTU accomplished. Missing element. No goal knowledge. Info is solely what “shopper” offered. Fundamental biographic knowledge offered. Included record of medicines and allergic reactions. Signs evaluation: PQRSTU accomplished. Detailed. No goal knowledge. Info is solely what “shopper” offered.
Factors: 1 Factors: 2 Factors: three Factors: four
Goal
(four Pts) Lacking elements of evaluation for explicit system. Might include subjective knowledge. Might have indicators of bias or clarification of findings. Might have included phrases comparable to “regular”, “acceptable”,
“okay”, and “good”.
Consists of all elements of evaluation for explicit system. Lacks element. Makes use of phrases comparable to “regular”, “acceptable”, or “good”. Incorporates all goal data. Might have indicators of bias or clarification of findings. Consists of all elements of evaluation for explicit system. Averted use of phrases comparable to “regular”, “acceptable”, or “good”. No bias or clarification for findings evident Incorporates all goal data Consists of all elements of evaluation for explicit system. Detailed data offered. Averted use of phrases comparable to “regular”, “acceptable”, or “good”. No bias or clarification for findings evident. All goal data
Factors: 1 Factors: 2 Factors: three Factors: four
Precise or Potential Threat Elements
(2 pts)
Lists one to 2 precise or potential threat elements for the shopper based mostly on the evaluation findings with no description or cause for choice of them. Failure to offer any potential or precise threat elements will lead to zero factors for this criterion. Transient description of 1 or two precise or potential threat elements for the shopper based mostly on the evaluation findings with description or cause for choice of them. Restricted description of two precise or potential threat elements for the shopper based mostly on the evaluation findings with description or cause for choice of them. Complete, detailed description of two precise or potential threat elements for the shopper based mostly on the evaluation findings with description or cause for choice of them.
Factors: zero.5 Factors: 1 Factors: 1.5 Factors: 2
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