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[SOLUTION] Problem Based Subjective and Objective Assessment of Gastrointestinal System – Expert Solution #1

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[SOLUTION] Problem Based Subjective and Objective Assessment of Gastrointestinal System – Expert Solution

Title: Documentation of problem based assessment of the gastrointestinal system. Purpose of Assignment: Learning the required components of documenting a problem based subjective and objective assessment of gastrointestinal system. Identify abnormal findings. Problem Based Subjective and Objective Assessment of Gastrointestinal System Course Competency: Prioritize appropriate assessment techniques for the gastrointestinal, breasts, and genitourinary systems.
[SOLUTION] Problem Based Subjective and Objective Assessment of Gastrointestinal System - Expert Solution

[SOLUTION] Problem Based Subjective and Objective Assessment of Gastrointestinal System – Expert Solution

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.) Problem Based Subjective and Objective Assessment of Gastrointestinal System
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.
Problem Based Subjective and Objective Assessment of Gastrointestinal System

Problem Based Subjective and Objective Assessment of Gastrointestinal System

Documentation Grading Rubric- 10 possible points
Levels of Achievement
Criteria Emerging Competence Proficiency Mastery
Subjective (4 Pts) Problem Based Subjective and Objective Assessment of Gastrointestinal System 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. Problem Based Subjective and Objective Assessment of Gastrointestinal System Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Lacking detail. No objective data. Information is solely what “client” provided. Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Detailed. No objective data. Information is solely what “client” provided.
Points: 1 Points:  2 Points: 3 Points: 4
Objective (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”. 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 Problem Based Subjective and Objective Assessment of Gastrointestinal System 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: 1 Points: 2 Points: 3 Points: 4
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. 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. Problem Based Subjective and Objective Assessment of Gastrointestinal System 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. Problem Based Subjective and Objective Assessment of Gastrointestinal System
Points: 0.5 Points: 1 Points: 1.5 Points: 2

Problem Based Subjective and Objective Assessment of Gastrointestinal System

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