RC Head to Toe Assessment Physical Examination of The 54yo Patient Mrs J Case Study

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.

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&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- 20 possible points
Levels of Achievement
Criteria
Emerging
Competence
Proficiency
Mastery
Objective
(16 Pts)
Actual or
Potential Risk
Factors
(4 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.
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.
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
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: 11
Points: 14
Points: 15
Points: 16
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: 1
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: 2
Points: 3
Points: 4
Points: 12
Points: 16
Points: 18
Points: 20