musculoskeletal system

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:

  • Use of three sections: Subjective, Objective, and Abnormal Findings
  • Short descriptive paragraph of findings for each section, including strengths and weaknesses.

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://sear…

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

(12 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 criteria.
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: 9 Points:12 Points: 13.5 Points: 15
Strength and Weakness

(4 Pts)

Lists one strength and one weakness with no description or reason for selection of them. Failure to provide both one strength and weakness will result in zero points for this criteria. Provides brief description of one strength and one weakness with no reason for identification of the strength and weakness. Provides description of one strength and one weakness noted on assessment. Gives reason for identification of the strength and weakness. Detailed description of one strength and one weakness noted during assessment. Detailed reason provided for identifying the strength and weakness.
Points: 1.8 Points: 2.4 Points: 2.7 Points: 3
Spelling and Grammar

(4 Pt)

Six or more spelling or grammar errors.Detracts from the readability of the submission. No more than five spelling or grammar errors, minimally detracts from the readability of the submission. No more than three spelling or grammar errors.Does not detract from the readability of the submission. No spelling or grammar errors.
Points: 1.2 Points: 1.6 Points: 1.8 Points: 2
Points: 12 Points: 16 Points: 18

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