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Overview: Module 3 A and 3B Subjective and Objective Data Collection

Use the interview guides and assessment forms for the topics we are covering and fill in the forms. See the module 1 assignment instructions to refresh your memory if you are not sure about saving or submitting the work. You don’t have to use the same person for the entire class—try to find assessment partners among people who actually have health problems so that you get experience assessing and documenting abnormal findings if possible. Because you are covering more assessment topics this week, they will be turned in as two assignments.

On the Module 3 assignment forms, you will find the following items: • Eyes • Ears • Mouth

• Nose • Throat • Sinuses

Remember not to use terms like “good”, “normal” and “NA”. From this week forward, you may not use terms in describing skin such as “spot”, “bump” or “pimple”—you need to use professional language. We expect you to use “macule”, “papule” and “pustule” appropriately. Read the section in your book thoroughly which describes skin lesions—these will be on the quiz!

Overview

SBAR –no SBAR this time.

Submitting your assignment

 Save this document to your computer as a Word document.

 Open the document from your desktop and type your information directly into the assignment areas provided on the template.

 Save the completed document template as a Word document (not odt.).

 Return to Blackboard and upload to the assignment portal.

Module 3 A Assignment: Eyes, ears, and Module 3B Assignment mouth, throat and sinuses.

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Rubric for Assignment 3A and B

Excellent Good Needs Work Needs extensive work

Clearly incomplete

Use of specifically prohibited

terminology

20 Points Uses no vague

terms such as

good, normal,

N/A or not

applicable

15 Points 1 - 3 incorrect

terms are

used.

10 Points 4 - 5 incorrect

terms are used.

5 Points 6 - 8

incorrect

terms are

used.

0 Points 9 or more

incorrect

terms used.

Assessment descriptions

70 points All descriptions are appropriate & complete, describing findings as unilateral/bilateral, symmetrical or asymmetrical when appropriate. Uses correct units of measurement and documentation— such as mmHG, breaths/minute, etc.

60 points 1 - 5 descriptions that are not complete, or an area is missing/blank.

50 points 6 to 10 or more descriptions are incomplete or two areas are missing/blank.

30 points Several areas are incomplete, or more than 2-4 areas are missing information/bl ank.

5 points Most descriptions are incomplete or more than 4 areas of the assessment are blank.

Grammar

10 Points Short sentences

or phrases are

used, no

grammatical

errors.

8 Points One to two

grammatical

errors

5 Points three to five

grammatical

errors

2 Points Six to eight

grammatical

errors

0 Points Entire

document is

ungrammati

cal, greater

than 8

grammatical

errors.

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Performance Objectives:

 Collect subjective and objective data to include present health concerns, past health history, family history and lifestyle/health practices relating to, and physical assessment of:

• Eyes • Ears

• Mouth • Nose

• Throat • Sinuses

N3425 Holistic Health Assessment

Rubric grading of assessment forms

One point is subtracted for each occurrence of the following, up to 10 points or more total for

the form. (Meaning students can’t get an A on the assessment if they use one of the

following 10 or more times.) See rubric for application in each form.

1. NA or Not applicable.

For this class, N/A or not applicable is appropriate only concerning the reproductive

system, if the item refers to a finding or process which does not apply to the sex of

the patient. For instance, date of last menstrual period (LMP): If the patient is male,

putting N/A for that item is allowed.

2. Good. For instance, referring to skin turgor as “good” is not sufficiently specific for

this class. Students need to describe the good finding: Elastic, for instance.

3. Normal. In this assessment class, students need to be more specific. Describing

bowel sounds as “normal in all 4 quadrants” is fine in a clinical setting, but for

purposes of this class, more specificity is required. The term “active” describes what

normal is, and is what is needed here.

4. Within normal limits. Describe what was found, even if that is normal. This makes

you use the terminology—say it. There are examples in the textbook for most

findings.

5. Appropriate. For this class, describe what you mean rather than using the

description “appropriate.” The word can be very vague and it doesn’t mean the same

thing every time it is used—the meaning varies with the situation. Use a word that

has a definite meaning!

Here are a couple of things to keep in mind, and they are in table form, below:

When interviewing the assessment partner for the subjective finding, if the partner denies

having a problem, using the word “denies” is not sufficient documentation for that entry.

State what is denied.

Give a full description of findings for each entry, not leaving any blanks.

When describing a finding, state whether it is unilateral (on the left or the right) or bilateral.

Use units of measure: mmHg, millimeters. Your book no longer requires the use of

denominators for reporting strength (___out of 6) or reflexes (__out of 4) so you won’t get

N3425 Holistic Health Assessment

points off for not using them, but they are still a good idea, and we encourage their use in

your assessments and in your employment. Do you remember “off the top of your head”

what a reflex is scored out of: 4, 5, or 6? It is 4, actually, but we can’t all remember for

every assessment! Assume the person reading the form doesn’t know the normal unit, and

you must supply it.

Section of the Paper

Expectation (See Grading Rubric)

Error

Format Not

followed

Spelling Incorrect

Font An easily readable font such as Times New Roman, Ariel, or Calibri

Template

Not followed

Subjective Data See textbook or examples

Subjective and objective

Separate subjective and objective data Mixed up data

Follow template

Submission per stated guidelines

See Syllabus and instructions late

Describe assessment, avoid using vague terms such as normal, NA, good, etc.

Uses terms not allowed

If patient does not have finding, must state “denies __________”.

States only “denies”

Ecomap Detail

Accuracy

Legend

Legibility

Client not on legend

No names – use initials or relationships

Lymph nodes Missing name and / or Bilateral-each

Tonsils Bilateral, 0 to 4+

N3425 Holistic Health Assessment

TMJ Bilateral

Sinuses Percussion and/ or Transillumination Bilateral

Thyroid No masses and/ or Bilateral/bruits

MSK Name, ROM and / or Bilateral each

Temporal Artery

Bilateral

Carotid Artery Bilateral

Tympanic Membrane

Bilateral

Canal/cerumen Bilateral

Pinna, Tragus, Lobe

Bilateral

Neurological Technique (CN 1-Separate scents for each nostril)

CN name, number and correct test each error

Reflexes 1+ to 4+

Nails Cap Refill and /or angle with # of digits X10 digits

Resp Rate Breaths per minute Not listed as breaths/min

Heart Rate Beats per minute Not in cardiac

APETM Aortic

Pulmonic Erb’s point Tricuspid Mitral Abnormal heart sound name, grade, etc.

Not complete in Cardiac

Pulses Bilateral using amplitude scale in book: 0 – 4+