Posted: May 1st, 2022

Physical Assessment

Title:
Documentation of all the head to toe bodily analysis.

Goal of Mission:
To disclose the facility to doc the findings of an aim head to toe analysis and set up irregular findings.

Course Competency:
Show bodily examination talents of the pores and pores and skin, hair, nails, and musculoskeletal system.
Prioritize relevant analysis strategies for the gastrointestinal, breasts, and genitourinary strategies.
Show bodily examination talents of the highest, ears, and eyes, nostril, mouth, neck, and regional lymphatics.
Apply analysis strategies for the neurological and respiratory strategies.
Select relevant bodily examination talents for the cardiovascular and peripheral vascular strategies.

Instructions:

Content material materials:
• Aim findings along with fast descriptive paragraph of findings for each half.
• Exact or potential menace parts for the patron based mostly totally on the analysis findings with description or motive for selection of them.

Format:
• Regular American English (acceptable grammar, punctuation, and so forth.)

Sources:
Chapter 5: SOAP Notes: The subjective and aim portion solely
Sullivan, D. D. (2012). Info 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&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&site=eds-live

Documentation Grading Rubric- 20 doable components
Ranges of Achievement
Requirements Rising Competence Proficiency Mastery
Aim
(16 Pts) Missing components of analysis for express system. Might comprise subjective information. Might have indicators of bias or rationalization of findings. Might have included phrases much like “common”, “relevant”,
“okay”, and “good”.
Failure to supply any aim information will finish in zero components for this criterion. Consists of all components of analysis for express system. Lacks aspect. Makes use of phrases much like “common”, “relevant”, or “good”. Includes all aim knowledge. Might have indicators of bias or rationalization of findings. Consists of all components of analysis for express system. Prevented use of phrases much like “common”, “relevant”, or “good”. No bias or rationalization for findings evident Includes all aim knowledge Consists of all components of analysis for express system. Detailed knowledge provided. Prevented use of phrases much like “common”, “relevant”, or “good”. No bias or rationalization for findings evident. All aim knowledge
Elements: 11 Elements: 14 Elements: 15 Elements: 16
Exact or Potential Hazard Parts (4 Pts) Lists one to 2 exact or potential menace parts for the patron based mostly totally on the analysis findings with no description or motive for selection of them. Failure to supply any potential or exact menace parts will finish in zero components for this criterion. Short-term description of 1 or two exact or potential menace parts for the patron based mostly totally on the analysis findings with description or motive for selection of them. Restricted description of two exact or potential menace parts for the patron based mostly totally on the analysis findings with description or motive for selection of them. Full, detailed description of two exact or potential menace parts for the patron based mostly totally on the analysis findings with description or motive for selection of them.
Elements: 1 Elements: 2 Elements: three Elements: 4
Elements: 12 Elements: 16 Elements: 18 Elements: 20

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