Assignment: Guide to clinical documentation

You will perform a history of a nose, mouth, throat, or neck problem that your instructor has provided you or one that you have experienced, and you will perform an assessment including nose, mouth, throat, and neck. You will document your subjective and objective findings, identify actual or potential risks, and submit this in a Word document to the drop box provided.

Nose, Mouth, Throat, and Neck Assignment

Documentation of problem based assessment of the nose, throat, neck, and regional lymphatics.

Purpose of Assignment:

Learning the required components of documenting a problem based subjective and objective assessment of nose, throat, neck, and regional lymphatics. Identify abnormal findings.

Course Competency:

Demonstrate physical examination skills of the head, ears, and eyes, nose, mouth, neck, and regional lymphatics.

ORDER CUSTOM, PLAGIARISM-FREE PAPER

Instructions:

Content: Use of three sections:

· Subjective

· Objective

· 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

Assignment: Guide to clinical documentation

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- 10 possible points

Levels of Achievement
Criteria	Emerging	Competence	Proficiency	Mastery
Subjective (4 Pts)	Missing components such as biographic data, medications, or allergies. Symptoms analysis is incomplete. May contain objective data.	Basic biographic data provided. Medications and allergies included. Symptoms analysis incomplete. Lacking detail. No objective data.	Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Lacking detail. No objective data. Information is solely what “client” provided.	Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Detailed. No objective data. Information is solely what “client” provided.
	Points: 1	Points: 2	Points: 3	Points: 4
Objective (4 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”.	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: 1	Points: 2	Points: 3	Points: 4