90 year female resident with a stroke
Title:
Documentation of problem based assessment of the cardiac system.
Purpose of Assignment:
Learning the required components of documenting a problem based subjective and objective assessment of cardiac system. Identify abnormal findings.
Course Competency:
Select appropriate physical examination skills for the cardiovascular and peripheral vascular systems.
Instructions:
Content: Use of three sections:
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 fromhttp://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 >
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