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

Title:

Documentation of the complete head to toe physical assessment.

Purpose of Assignment:

To demonstrate the ability to document the findings of an objective head to toe assessment and identify abnormal findings.

Course Competency:

Demonstrate physical examination skills of the skin, hair, nails, and musculoskeletal system.
Prioritize appropriate assessment techniques for the gastrointestinal, breasts, and genitourinary systems.
Demonstrate physical examination skills of the head, ears, and eyes, nose, mouth, neck, and regional lymphatics.
Apply assessment techniques for the neurological and respiratory systems.
Select appropriate physical examination skills for the cardiovascular and peripheral vascular systems.

Instructions:

Content:

· Objective findings including short descriptive paragraph of findings for each section.
· Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.

Format:

· Standard American English (correct grammar, punctuation, etc.)

Resources:

Chapter 5: SOAP Notes: The subjective and objective portion only
Sullivan, D. D. (2012). Guide to clinical 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 possible points

Levels of Achievement

Criteria

Emerging

Competence

Proficiency

Mastery

Objective

(16 Pts)

Missing components of assessment for particular system. May contain subjective data. May have signs of bias or explanation of findings. May have included words such as “normal”, “appropriate”,
“okay”, and “good”.

Failure to provide any objective data will result in zero points for this criterion.

Includes all components of assessment for particular system. Lacks detail. Uses words such as “normal”, “appropriate”, or “good”. Contains all objective information. May have signs of bias or explanation of findings.

Includes all components of assessment for particular system. Avoided use of words such as “normal”, “appropriate”, or “good”. No bias or explanation for findings evident Contains all objective information

Includes all components of assessment for particular system. Detailed information provided. Avoided use of words such as “normal”, “appropriate”, or “good”. No bias or explanation for findings evident. All objective information

Points: 11

Points: 14

Points: 15

Points: 16

Actual or Potential Risk Factors (4 Pts)

Lists one to two actual or potential risk factors for the client based on the assessment findings with no description or reason for selection of them. Failure to provide any potential or actual risk factors will result in zero points for this criterion.

Brief description of one or two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.

Limited description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.

Comprehensive, detailed description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.

Points: 1

Points: 2

Points: 3

Points: 4

Points: 12

Points: 16

Points: 18

Points: 20

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