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, and Abnormal Findings
Short descriptive paragraph of findings for each section
Format:
Standard American English (correct grammar, punctuation, etc.)
Resources:
Chapter 5: SOAP Notes: The subjective and objective portion Assessment and nursing intervention.
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