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. (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
