Posted: May 1st, 2022

Physical Assessment

Title:
Documentation of downside based mostly evaluation of the peripheral vascular system.

Objective of Project:
Studying the required parts of documenting an issue based mostly subjective and goal evaluation of peripheral vascular system. Establish irregular findings.

Course Competency:
Choose applicable bodily examination abilities for the cardiovascular and peripheral vascular methods.

Directions:

Content material: Use of three sections:
o Subjective
o Goal
o Precise or potential danger elements for the shopper based mostly on the evaluation findings with no description or motive for choice of them.

Format:
• Normal American English (appropriate grammar, punctuation, and many others.)

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&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 attainable factors
Ranges of Achievement
Standards Rising Competence Proficiency Mastery
Subjective
(four Pts) Lacking parts corresponding to biographic knowledge, medicines, or allergic reactions. Signs evaluation is incomplete. Could include goal knowledge.
Primary biographic knowledge supplied. Drugs and allergic reactions included. Signs evaluation incomplete. Missing element. No goal knowledge. Primary biographic knowledge supplied. Included record of medicines and allergic reactions. Signs evaluation: PQRSTU accomplished. Missing element. No goal knowledge. Data is solely what “shopper” supplied. Primary biographic knowledge supplied. Included record of medicines and allergic reactions. Signs evaluation: PQRSTU accomplished. Detailed. No goal knowledge. Data is solely what “shopper” supplied.
Factors: 1 Factors: 2 Factors: three Factors: four
Goal
(four Pts) Lacking parts of evaluation for explicit system. Could include subjective knowledge. Could have indicators of bias or clarification of findings. Could have included phrases corresponding to “regular”, “applicable”,
“okay”, and “good”.
Consists of all parts of evaluation for explicit system. Lacks element. Makes use of phrases corresponding to “regular”, “applicable”, or “good”. Comprises all goal data. Could have indicators of bias or clarification of findings. Consists of all parts of evaluation for explicit system. Prevented use of phrases corresponding to “regular”, “applicable”, or “good”. No bias or clarification for findings evident Comprises all goal data Consists of all parts of evaluation for explicit system. Detailed data supplied. Prevented use of phrases corresponding to “regular”, “applicable”, or “good”. No bias or clarification for findings evident. All goal data
Factors: 1 Factors: 2 Factors: three Factors: four
Precise or Potential Danger Elements
(2 pts)
Lists one to 2 precise or potential danger elements for the shopper based mostly on the evaluation findings with no description or motive for choice of them. Failure to supply any potential or precise danger elements will end in zero factors for this criterion. Transient description of 1 or two precise or potential danger elements for the shopper based mostly on the evaluation findings with description or motive for choice of them. Restricted description of two precise or potential danger elements for the shopper based mostly on the evaluation findings with description or motive for choice of them. Complete, detailed description of two precise or potential danger elements for the shopper based mostly on the evaluation findings with description or motive for choice of them.
Factors: zero.5 Factors: 1 Factors: 1.5 Factors: 2

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