Posted: February 26th, 2022

Module 11 Lab Assignment – Documentation of Complete Head to Toe Physical Assessment

Module 11 Lab Assignment – Documentation of Complete Head to Toe Physical Assessment

Module 11 Lab Assignment – Documentation of Complete Head to Toe Physical Assessment

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Module 11 Content material

1.

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You accomplished your full head-to-toe Assessment abilities demonstration final week and now will doc your outcomes. Proceed to doc solely the target findings for this part with out bias or rationalization. Bear in mind if you happen to can’t really feel one thing then it’s “nonpalpable,” if you happen to can’t hear one thing simply state they weren’t heard akin to no bowel sounds heard (except you listened for the total 5 minutes which we wouldn’t need to do for our functions – then you might doc absent bowel sounds). Be descriptive if needed however on the identical time be transient.

Complete Head-to-Toe Physical Assessment Assignment.docx

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Title:

Documentation of the entire head to toe bodily Assessment.

Goal of Assignment:

To show the power to doc the findings of an goal head to toe Assessment and establish irregular findings.

Course Competency:

Show bodily examination abilities of the pores and skin, hair, nails, and musculoskeletal system.

Prioritize applicable Assessment methods for the gastrointestinal, breasts, and genitourinary techniques.

Show bodily examination abilities of the pinnacle, ears, and eyes, nostril, mouth, neck, and regional lymphatics.

Apply Assessment methods for the neurological and respiratory techniques.

Choose applicable bodily examination abilities for the cardiovascular and peripheral vascular techniques.

Directions:

Content material:

· Goal findings together with quick descriptive paragraph of findings for every part.

· Precise or potential threat elements for the shopper primarily based on the Assessment findings with description or purpose for choice of them.

Format:

· Normal American English (appropriate grammar, punctuation, and so on.)

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&website=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&website=eds-live

Documentation Grading Rubric- 20 attainable factors

Ranges of Achievement

Standards

Rising

Competence

Proficiency

Mastery

Goal

(16 Pts)

Lacking parts of Assessment for explicit system. Might include subjective information. Might have indicators of bias or rationalization of findings. Might have included phrases akin to “regular”, “applicable”, “okay”, and “good”.

Failure to present any goal information will end in zero factors for this criterion.

Consists of all parts of Assessment for explicit system. Lacks element. Makes use of phrases akin to “regular”, “applicable”, or “good”. Incorporates all goal data. Might have indicators of bias or rationalization of findings.

Consists of all parts of Assessment for explicit system. Prevented use of phrases akin to “regular”, “applicable”, or “good”. No bias or rationalization for findings evident Incorporates all goal data

Consists of all parts of Assessment for explicit system. Detailed data supplied. Prevented use of phrases akin to “regular”, “applicable”, or “good”. No bias or rationalization for findings evident. All goal data

Factors: 11

Factors: 14

Factors: 15

Factors: 16

Precise or Potential Danger Components (four Pts)

Lists one to two precise or potential threat elements for the shopper primarily based on the Assessment findings with no description or purpose for choice of them. Failure to present any potential or precise threat elements will end in zero factors for this criterion.

Transient description of one or two precise or potential threat elements for the shopper primarily based on the Assessment findings with description or purpose for choice of them.

Restricted description of two precise or potential threat elements for the shopper primarily based on the Assessment findings with description or purpose for choice of them.

Complete, detailed description of two precise or potential threat elements for the shopper primarily based on the Assessment findings with description or purpose for choice of them.

Factors: 1

Factors: 2

Factors: three

Factors: four

Factors: 12

Factors: 16

Factors: 18

Factors: 20

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Module 11 Lab Assignment – Complete Head to Toe Physical Assessment Documentation

Module 11 Lab Assignment – Complete Head to Toe Physical Assessment Documentation

Wonderful Type

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Module Eleven Content material

1.

Wonderful Type

You completed your complete head-to-toe Assessment abilities demonstration final week and can now doc your findings. For this part, proceed to doc merely the target findings with out bias or interpretation. Bear in mind if you happen to can’t really feel one thing then it’s “nonpalpable,” if you happen to can’t hear one thing simply state they weren’t heard akin to no bowel sounds heard (except you listened for the total 5 minutes which we wouldn’t need to do for our functions – then you might doc absent bowel sounds). Be descriptive if needed however on the

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