PA

Module 10 Lab Assignment – Documentation of an Examination of the Peripheral Vascular System

Module 10 Lab Assignment – Documentation of an Examination of the Peripheral Vascular System

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Module 10 Content

1.

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You will perform a history of a peripheral vascular problem that your instructor has provided you or one that you have experienced and perform a peripheral vascular assessment. You will document your subjective and objective findings, identify actual or potential risks, and submit this in a Word document to the drop box provided.

Peripheral Vascular System Assignment

Submit your completed assignment by following the directions linked below. Please check the Course Calendar for specific due dates.

Save your assignment as a Microsoft Word document. (Mac users, please remember to append the ” x” extension to the filename.) The name of the file should be your first initial and last name, followed by an underscore and the name of the assignment, and an underscore and the date. An example is shown below:

Title:

Documentation of problem based assessment of the peripheral vascular system.

Purpose of Assignment:

Learning the required components of documenting a problem based subjective and objective assessment of peripheral vascular system. Identify abnormal findings.

Course Competency:

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

Instructions:

Content: Use of three sections:

0. Subjective

0. Objective

0. Actual or potential risk factors for the client based on the assessment findings with no description or reason for selection of them.

Format:

1. 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 >

Documentation Grading Rubric- 10 possible points

Points: 1

Points: 3

Points: 4

Points: 1

Points: 2

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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 x

Submit your completed assignment by following the directions linked below. Please check the 
Course Calendar
 for specific due dates.

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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. (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- 20 possible points

Points: 16