Module 05 Lab Assignment – Documentation of an Assessment of the Head, Ears, and Eyes -Science
You will perform a history of a head, ear, or eye problem that your instructor has provided you or one that you have experienced and perform an assessment including head, ears, and eyes. You will document your findings, note any abnormal findings, and submit this in a Word document to the drop box provided.HEENT AssignmentSubmit 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 “.docx” 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:Jstudent_exampleproblem_101504
head.docx
Unformatted Attachment Preview
Title:
Documentation of problem based assessment of the head, ears, and eyes.
Purpose of Assignment:
Learning the required components of documenting a problem based subjective and objective
assessment of a head, ears, and eyes. 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: Subjective, Objective, and Abnormal Findings
Short descriptive paragraph of findings for each section
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
contain objective
data.
Basic biographic
data provided.
Medications and
allergies included.
Symptoms analysis
incomplete. Lacking
detail. No objective
data.
Basic biographic
data provided.
Included list of
medications and
allergies. Symptoms
analysis: PQRSTU
completed. Lacking
detail. No objective
data. Information is
Basic biographic
data provided.
Included list of
medications and
allergies. Symptoms
analysis: PQRSTU
completed. Detailed.
No objective data.
Information is solely
Objective
(4 Pts)
(2 Pts)
what “client”
provided.
Points: 0.5
Points: 1
Points: 2
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
Provides brief
description of one
strength and one
weakness with no
reason for
identification of the
strength and
weakness.
Provides description
of one strength and
one weakness noted
on assessment.
Gives reason for
identification of the
strength and
weakness.
Detailed description
of one strength and
one weakness noted
during assessment.
Detailed reason
provided for
identifying the
strength and
weakness.
Points: 1
Points: 1.5
Points: 2
Points: 1
Strength and
Weakness
solely what “client”
provided.
Lists one strength
and one weakness
with no description
or reason for
selection of them.
Failure to provide
both one strength
and weakness will
result in zero points
for this criteria.
Points: 0.5
…
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