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. Course Competency: Prioritize appropriate assessment techniques for the gastrointestinal, breasts, and genitourinary systems. Instructions: Content: Use of three sections: o o o Subjective Objective 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.) Resources: Chapter 5: SOAP Notes: The subjective and objective portion only Sullivan, D. D. (2012). Guide to clinical documentation. [E-Book]. Retrieved from http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&d b=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&d b=rzh&AN=107055742&site=eds-live Documentation Grading Rubric- 10 possible points Levels of Achievement Criteria Subjective (4 Pts) Emerging Missing components such as biographic data, medications, or allergies. Symptoms analysis is Competence Basic biographic data provided. Medications and allergies included. Symptoms analysis Proficiency Mastery Basic biographic data provided. Included list of medications and allergies. Symptoms Basic biographic data provided. Included list of medications and allergies. Symptoms Objective (4 Pts) incomplete. May contain objective data. incomplete. Lacking detail. No objective data. Points: 1 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”. Points: 1 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. Points: 0.5 Points: 2 analysis: PQRSTU completed. Lacking detail. No objective data. Information is solely what “client” provided. Points: 3 analysis: PQRSTU completed. Detailed. No objective data. Information is solely what “client” provided. Points: 4 Includes 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. Points: 2 Includes 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 Points: 3 Includes 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: 4 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: 1 Points: 1.5 Points: 2 Title: Documentation of problem based assessment of the head, ears, and eyes. Purpose of Assignment: Learning the required components of documenting a problem based subjective and objective assessment of a head, ears, and eyes. Identify abnormal findings. Course Competency: Demonstrate physical examination skills of the head, ears, and eyes, nose, mouth, neck, and regional lymphatics. Instructions: Content: Use of three sections: o o o Subjective Objective 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.) Resources: Chapter 5: SOAP Notes: The subjective and objective portion only Sullivan, D. D. (2012). Guide to clinical documentation. [E-Book]. Retrieved from http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&d b=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&d b=rzh&AN=107055742&site=eds-live Documentation Grading Rubric- 10 possible points Levels of Achievement Criteria Subjective (4 Pts) Emerging Competence Proficiency Mastery Missing components such as biographic data, medications, or allergies. Symptoms analysis is incomplete. May Basic biographic data provided. Medications and allergies included. Symptoms analysis incomplete. Lacking Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Lacking Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Detailed. Objective (4 Pts) contain objective data. detail. No objective data. detail. No objective data. Information is solely what “client” provided. No objective data. Information is solely what “client” provided. Points: 1 Points: 2 Points: 3 Points: 4 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”. Includes 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. Points: 2 Includes 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 Points: 3 Includes 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: 4 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: 1 Points: 1.5 Points: 2 Points: 1 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. Points: 0.5 Title: Documentation of problem based assessment of the nose, throat, neck, and regional lymphatics. Purpose of Assignment: Learning the required components of documenting a problem based subjective and objective assessment of nose, throat, neck, and regional lymphatics. Identify abnormal findings. Course Competency: Demonstrate physical examination skills of the head, ears, and eyes, nose, mouth, neck, and regional lymphatics. Instructions: Content: Use of three sections: o o o Subjective Objective 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.) Resources: Chapter 5: SOAP Notes: The subjective and objective portion only Sullivan, D. D. (2012). Guide to clinical documentation. [E-Book]. Retrieved from http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&d b=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&d b=rzh&AN=107055742&site=eds-live Documentation Grading Rubric- 10 possible points Levels of Achievement Criteria Subjective (4 Pts) Emerging Competence Proficiency Mastery Missing components such as biographic data, medications, or allergies. Symptoms analysis is incomplete. May Basic biographic data provided. Medications and allergies included. Symptoms analysis incomplete. Lacking Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Lacking Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Detailed. Objective (4 Pts) contain objective data. detail. No objective data. detail. No objective data. Information is solely what “client” provided. No objective data. Information is solely what “client” provided. Points: 1 Points: 2 Points: 3 Points: 4 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”. Includes 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. Points: 2 Includes 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 Points: 3 Includes 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: 4 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: 1 Points: 1.5 Points: 2 Points: 1 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. Points: 0.5 Title: Documentation of problem based assessment of the neurological system. Purpose of Assignment: Learning the required components of documenting a problem based subjective and objective assessment of neurological system. Identify abnormal findings. Course Competency: Apply assessment techniques for the neurological and respiratory systems. Instructions: Content: Use of three sections: o o o Subjective Objective 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.) Resources: Chapter 5: SOAP Notes: The subjective and objective portion only Sullivan, D. D. (2012). Guide to clinical documentation. [E-Book]. Retrieved from http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&d b=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&d b=rzh&AN=107055742&site=eds-live Documentation Grading Rubric- 10 possible points Levels of Achievement Criteria Subjective (4 Pts) Emerging Competence Proficiency Mastery 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. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Lacking detail. No objective Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Detailed. No objective data. Objective (4 Pts) Information is solely what “client” provided. Points: 1 Points: 2 Points: 3 Points:4 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”. Includes 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. Points: 2 Includes 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 Points: 3 Includes 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: 4 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: 1 Points: 1.5 Points: 2 Points: 1 Actual or Potential Risk Factors (2 pts) data. Information is solely what “client” provided. 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. Points: 0.5 Title: Documentation of problem based assessment of the respiratory system. Purpose of Assignment: Learning the required components of documenting a problem based subjective and objective assessment of respiratory system. Identify abnormal findings. Course Competency: Apply assessment techniques for the neurological and respiratory systems. Instructions: Content: Use of three sections: o o o Subjective Objective 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.) Resources: Chapter 5: SOAP Notes: The subjective and objective portion only Sullivan, D. D. (2012). Guide to clinical documentation. [E-Book]. Retrieved from http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&d b=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&d b=rzh&AN=107055742&site=eds-live Documentation Grading Rubric - 10 possible points Levels of Achievement Criteria Subjective (4 Pts) Emerging Competence Proficiency Mastery 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. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Lacking detail. No objective Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Detailed. No objective data. Objective (4 Pts) Information is solely what “client” provided. Points: 1 Points: 2 Points: 3 Points: 4 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”. Includes 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. Points: 2 Includes 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 Points: 3 Includes 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: 4 Brief description of one or two actual or potential risk factors for the client based on the 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: 1 Points: 1.5 Points: 2 Points: 1 Actual or Potential Risk Factors (2 pts) data. Information is solely what “client” provided. 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. Points: 0.5
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