homework

mercy@0sw
10Resources.docx

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

Physical Examination and Health Assessment

Carolyn Jarvis

The book to use for all the references