Rasmussen Minneapolis Minnesota Nose Mouth and Throat Health History Documentation

Documentation of the Nose, Mouth, and Throat

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Examiner:

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Date:

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Patient:

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Age:

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Reason for Visit:

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Health History – Nose

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  • Any nasal discharge noted?
  • Unusually frequent of severe colds?
  • Any sinus pain or sinusitis?
  • Any trauma or injury to the nose?
  • Any nosebleeds? How often?
  • Any allergies or hay fever?
  • Any changes or loss in the sense of smell?
  • undefined

    Health History – Mouth

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  • Any sores in the mouth or on the tongue?
  • Any sore throat? How often?
  • Any bleeding gums or toothache?
  • Any hoarseness or voice change?
  • Any difficulty swallowing?
  • Any change in the sense of taste?
  • Do you smoke? How much per day? How long?
  • Drink alcohol? How many times per week? How many drinks per occasion?
  • Do you use nasal sprays?
  • Do you get regular dental checkups? Brush your teeth and floss daily?
  • undefined

    Health History – Throat

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  • Any neck pain?
  • Any lumps or masses in the neck?
  • Any surgery on the neck?
  • Any history of thyroid problems?
  • undefined

    Physical Assessment

    undefinedInspect the nose and palpate sinusesSymmetrical?Nares patent?Deviated septum?Mucous membranes pink and moist? Discharge or inflammation?Any tenderness in frontal or maxillary sinuses?Inspect the mouthLips symmetrical? Lesions? Dry or chapped?Dentition intact? Caries?Gums inflamed?Any lesions in the mouth? Membranes pink and moist?Tongue midline? Able to move? Uvula rises with phonation?Hard palate intact?Tonsils present? Inflamed?Inspect and palpate the neckTrachea midline?Thyroid enlarged or nodules present?Perform ROM ROM against resistance – head and shouldersPalpate lymph nodes – any tenderness or inflammation?undefined

    Regional Write-Up

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  • Subjective (Health History)
  • Objective (Physical Assessment)
  • Assessment of Risks and Plan (Include two risks)
  • Title:
    Documentation of problem based assessment of the nose, throat, neck, and regional lymphatics.
    Purpose of Assignment:
    Learning the required components of documenting a problem based subjective and objective
    assessment of nose, throat, neck, and regional lymphatics. Identify abnormal findings.
    Course Competency:
    Demonstrate physical examination skills of the head, ears, and eyes, nose, mouth, neck, and
    regional lymphatics.
    Instructions:
    Content: Use of three sections:
    o
    o
    o
    Subjective
    Objective
    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&d
    b=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&d
    b=rzh&AN=107055742&site=eds-live
    Documentation Grading Rubric- 10 possible points
    Levels of Achievement
    Criteria
    Subjective
    (4 Pts)
    Emerging
    Competence
    Proficiency
    Mastery
    Missing components
    such as biographic
    data, medications, or
    allergies. Symptoms
    analysis is
    incomplete. May
    Basic biographic
    data provided.
    Medications and
    allergies included.
    Symptoms analysis
    incomplete. Lacking
    Basic biographic
    data provided.
    Included list of
    medications and
    allergies. Symptoms
    analysis: PQRSTU
    completed. Lacking
    Basic biographic
    data provided.
    Included list of
    medications and
    allergies. Symptoms
    analysis: PQRSTU
    completed. Detailed.
    Objective
    (4 Pts)
    contain objective
    data.
    detail. No objective
    data.
    detail. No objective
    data. Information is
    solely what “client”
    provided.
    No objective data.
    Information is solely
    what “client”
    provided.
    Points: 1
    Points: 2
    Points: 3
    Points: 4
    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”.
    Includes 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.
    Points: 2
    Includes 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
    Points: 3
    Includes 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: 4
    Brief description of
    one or two actual or
    potential risk
    factors for the client
    based on
    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: 1.5
    Points: 2
    Points: 1
    Actual or
    Potential Risk
    Factors
    (2 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.
    Points: 0.5
    Documentation of the Nose, Mouth, and Throat
    Examiner:
    Date:
    Patient:
    Age:
    Reason for Visit:
    Health History – Nose
    1. Any nasal discharge noted?
    2. Unusually frequent of severe colds?
    3. Any sinus pain or sinusitis?
    4. Any trauma or injury to the nose?
    5. Any nosebleeds? How often?
    6. Any allergies or hay fever?
    7. Any changes or loss in the sense of smell?
    Health History – Mouth
    1. Any sores in the mouth or on the tongue?
    2. Any sore throat? How often?
    3. Any bleeding gums or toothache?
    4. Any hoarseness or voice change?
    5. Any difficulty swallowing?
    6. Any change in the sense of taste?
    7. Do you smoke? How much per day? How long?
    8. Drink alcohol? How many times per week? How many drinks per occasion?
    9. Do you use nasal sprays?
    10. Do you get regular dental checkups? Brush your teeth and floss daily?
    Health History – Throat
    1. Any neck pain?
    2. Any lumps or masses in the neck?
    3. Any surgery on the neck?
    4. Any history of thyroid problems?
    Physical Assessment
    1. Inspect the nose and palpate sinuses
    a. Symmetrical?
    b. Nares patent?
    c. Deviated septum?
    d. Mucous membranes pink and moist?
    e. Discharge or inflammation?
    f. Any tenderness in frontal or maxillary sinuses?
    2. Inspect the mouth
    a. Lips symmetrical? Lesions? Dry or chapped?
    b. Dentition intact? Caries?
    c. Gums inflamed?
    d. Any lesions in the mouth? Membranes pink and moist?
    e. Tongue midline? Able to move?
    f. Uvula rises with phonation?
    g. Hard palate intact?
    h. Tonsils present? Inflamed?
    3. Inspect and palpate the neck
    a. Trachea midline?
    b. Thyroid enlarged or nodules present?
    c. Perform ROM
    d. ROM against resistance – head and shoulders
    e. Palpate lymph nodes – any tenderness or inflammation?
    Regional Write-Up
    1. Subjective (Health History)
    2. Objective (Physical Assessment)
    3. Assessment of Risks and Plan (Include two risks)

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