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: 2024 – Write My Essay For Me | Essay Writing Service For Your Papers Online). 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. Get custom essay samples and course-specific study resources via course hero homework for you service – Include d 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. Get custom essay samples and course-specific study resources via course hero homework for you service – Include d 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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