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files (3)AssignmentInstructions_Module3EyesEarsandMouthNoseThroatSinuses.pdf
UPdatedCommonerrorsonassessmentforms.pdf
- Assignment3AEyesEars.docx
AssignmentInstructions_Module3EyesEarsandMouthNoseThroatSinuses.pdf
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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
UPdatedCommonerrorsonassessmentforms.pdf
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+
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