Module 08 Lab Assignment – Documentation a Respiratory Examination

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Module 08 Lab Assignment – Documentation a Respiratory Examination

You will perform a history of a respiratory problem that either your instructor has provided you or one that you have experienced and perform a respiratory assessment. 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.

Respiratory System Assignment

Submit your completed assignment by following the directions linked below. Please check the Course Calendar for specific due dates.

Save your assignment as a Microsoft Word document. (Mac users, please remember to append the “.docx” extension to the filename.) The name of the file should be your first initial and last name, followed by an underscore and the name of the assignment, and an underscore and the date. An example is shown below:

Jstudent_exampleproblem_101504

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Title:

Documentation of problem based assessment of the respiratory system.

Purpose of Assignment:

Learning the required components of documenting a problem based subjective and objective assessment of respiratory system. Identify abnormal findings. Module 08 Lab Assignment – Documentation a Respiratory Examination

 

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
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
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 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: 0.5 Points: 1 Points: 1.5 Points: 2

Module 09 Lab Assignment – Documentation of a Cardiovascular System Examination

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Module 09 Content

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You will perform a history of a cardiac problem that your instructor has provided you or one that you have experienced, and you will perform a cardiac assessment. 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. Module 08 Lab Assignment – Documentation a Respiratory Examination

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Cardiac System Assignment

 

Submit your completed assignment by following the directions linked below. Please check the Course Calendar for specific due dates.

 

Save your assignment as a Microsoft Word document. (Mac users, please remember to append the “.docx” extension to the filename.) The name of the file should be your first initial and last name, followed by an underscore and the name of the assignment, and an underscore and the date. An example is shown below:

Bottom of Form

 

Title:

Documentation of problem based assessment of the cardiac system.

 

Purpose of Assignment:

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

 

Course Competency:

Select appropriate physical examination skills for the cardiovascular and peripheral vascular 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 fromhttp://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
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
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. Module 08 Lab Assignment – Documentation a Respiratory Examination 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: 0.5 Points: 1 Points: 1.5 Points: 2