Documentation of problem based assessment of the neurological system

Title:

Documentation of problem based assessment of the neurological system.

Purpose of Assignment: 

Learning the required components of documenting a problem based subjective and objective assessment of neurological system. Identify abnormal findings.

Course Competency:

Apply assessment techniques for the neurological and respiratory systems.

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    

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
CriteriaEmergingCompetence ProficiencyMastery
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: 1Points: 2Points: 3Points: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 informationIncludes 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: 1Points: 2Points: 3Points: 4
Actual or     Potential Risk Factors(2 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 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: 0.5Points: 1Points: 1.5Points: 2
Place your order
(550 words)

Approximate price: $22

Calculate the price of your order

550 words
We'll send you the first draft for approval by September 11, 2018 at 10:52 AM
Total price:
$26
The price is based on these factors:
Academic level
Number of pages
Urgency
Basic features
  • Free title page and bibliography
  • Unlimited revisions
  • Plagiarism-free guarantee
  • Money-back guarantee
  • 24/7 support
On-demand options
  • Writer’s samples
  • Part-by-part delivery
  • Overnight delivery
  • Copies of used sources
  • Expert Proofreading
Paper format
  • 275 words per page
  • 12 pt Arial/Times New Roman
  • Double line spacing
  • Any citation style (APA, MLA, Chicago/Turabian, Harvard)

Our Guarantees

Money-back Guarantee

You have to be 100% sure of the quality of your product to give a money-back guarantee. This describes us perfectly. Make sure that this guarantee is totally transparent.

Read more

Zero-plagiarism Guarantee

Each paper is composed from scratch, according to your instructions. It is then checked by our plagiarism-detection software. There is no gap where plagiarism could squeeze in.

Read more

Free-revision Policy

Thanks to our free revisions, there is no way for you to be unsatisfied. We will work on your paper until you are completely happy with the result.

Read more

Privacy Policy

Your email is safe, as we store it according to international data protection rules. Your bank details are secure, as we use only reliable payment systems.

Read more

4-hour deadlines

Your urgent tasks will be completed within 4 hours. Your discussion responses and late orders will be will be handled fast and we still maintain our quality.

Read more
error: