Posted: May 1st, 2022

Module 11 Lab Assignment – Documentation of Complete Head to Toe Physical Assessment

Module 11 Lab Assignment – Documentation of Complete Head to Toe Physical Assessment

Module 11 Lab Assignment – Documentation of Complete Head to Toe Physical Assessment

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Module 11 Content

1.

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You completed your full head-to-toe assessment skills demonstration last week and now will document your results. Continue to document only the objective findings for this section without bias or explanation. Remember if you can’t feel something then it is “nonpalpable,” if you can’t hear something just state they were not heard such as no bowel sounds heard (unless you listened for the full five minutes which we wouldn’t want to do for our purposes – then you could document absent bowel sounds). Be descriptive if necessary but at the same time be brief.

Complete Head-to-Toe Physical Assessment Assignment.docx

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Title:

Documentation of the complete head to toe physical assessment.

Purpose of Assignment:

To demonstrate the ability to document the findings of an objective head to toe assessment and identify abnormal findings.

Course Competency:

Demonstrate physical examination skills of the skin, hair, nails, and musculoskeletal system.

Prioritize appropriate assessment techniques for the gastrointestinal, breasts, and genitourinary systems.

Demonstrate physical examination skills of the head, ears, and eyes, nose, mouth, neck, and regional lymphatics.

Apply assessment techniques for the neurological and respiratory systems.

Select appropriate physical examination skills for the cardiovascular and peripheral vascular systems.

Instructions:

Content:

· Objective findings including short descriptive paragraph of findings for each section.

· 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. (2014: 2024 – Essay Writing Service. Custom Essay Services Cheap). 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 ~ Hire our professional writers now and experience the best assignment help online with our custom paper writing service. We ensure your essays and assignments are expertly researched, written and delivered on time. ~ 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.

Get custom essay samples and course-specific study resources via course hero homework for you service – Include s 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.

Get custom essay samples and course-specific study resources via course hero homework for you service – Include s 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

Get custom essay samples and course-specific study resources via course hero homework for you service – Include s 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

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Module 11 Lab Assignment – Complete Head to Toe Physical Assessment Documentation

Module 11 Lab Assignment – Complete Head to Toe Physical Assessment Documentation

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Module Eleven Content

1.

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You finished your comprehensive head-to-toe assessment skills demonstration last week and will now document your findings. For this phase, continue to document simply the objective findings without bias or interpretation. Remember if you can’t feel something then it is “nonpalpable,” if you can’t hear something just state they were not heard such as no bowel sounds heard (unless you listened for the full five minutes which we wouldn’t want to do for our purposes – then you could document absent bowel sounds). Be descriptive if necessary but at the

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