Posted: May 1st, 2022

PYA essay

Title:
Documentation of disadvantage based analysis of the nostril, throat, neck, and regional lymphatics.

Goal of Process:
Learning the required components of documenting a problem based subjective and aim analysis of nostril, throat, neck, and regional lymphatics. Set up irregular findings.

Course Competency:
Show bodily examination skills of the top, ears, and eyes, nostril, mouth, neck, and regional lymphatics.

Instructions:

Content material materials: Use of three sections:
o Subjective
o Objective
o Exact or potential menace elements for the patron primarily based totally on the analysis findings with description or trigger for assortment of them.

Format:
• Commonplace American English (proper grammar, punctuation, and so forth.)

Property:
Chapter 5: SOAP Notes: The subjective and aim portion solely
Sullivan, D. D. (2012). Data 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 doable elements
Ranges of Achievement
Requirements Rising Competence Proficiency Mastery
Subjective
(4 Pts) Missing components equal to biographic data, medicine, or allergy signs. Indicators analysis is incomplete. Might embody aim data.
Main biographic data provided. Medication and allergy signs included. Indicators analysis incomplete. Lacking component. No aim data. Main biographic data provided. Included report of medicines and allergy signs. Indicators analysis: PQRSTU completed. Lacking component. No aim data. Information is solely what “shopper” provided. Main biographic data provided. Included report of medicines and allergy signs. Indicators analysis: PQRSTU completed. Detailed. No aim data. Information is solely what “shopper” provided.
Elements: 1 Elements: 2 Elements: three Elements: 4
Objective
(4 Pts) Missing components of analysis for specific system. Might embody subjective data. Might have indicators of bias or clarification of findings. Might have included phrases equal to “common”, “acceptable”,
“okay”, and “good”.
Incorporates all components of analysis for specific system. Lacks component. Makes use of phrases equal to “common”, “acceptable”, or “good”. Contains all aim data. Might have indicators of bias or clarification of findings. Incorporates all components of analysis for specific system. Averted use of phrases equal to “common”, “acceptable”, or “good”. No bias or clarification for findings evident Contains all aim data Incorporates all components of analysis for specific system. Detailed data provided. Averted use of phrases equal to “common”, “acceptable”, or “good”. No bias or clarification for findings evident. All aim data
Elements: 1 Elements: 2 Elements: three Elements: 4
Exact or Potential Menace Parts
(2 pts)
Lists one to 2 exact or potential menace elements for the patron primarily based totally on the analysis findings with no description or trigger for assortment of them. Failure to supply any potential or exact menace elements will finish in zero elements for this criterion. Non permanent description of 1 or two exact or potential menace elements for the patron primarily based totally on analysis findings with description or trigger for assortment of them. Restricted description of two exact or potential menace elements for the patron primarily based totally on the analysis findings with description or trigger for assortment of them. Full, detailed description of two exact or potential menace elements for the patron primarily based totally on the analysis findings with description or trigger for assortment of them.
Elements: zero.5 Elements: 1 Elements: 1.5 Elements: 2

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