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Documentation of problem based assessment of the musculoskeletal system.
Purpose of Assignment:
Learning the required components of documenting a problem based subjective and objective assessment of musculoskeletal system. Identify abnormal findings.
Course Competency:
Demonstrate physical examination skills of the skin, hair, nails, and musculoskeletal system.
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 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
Documentation Grading Rubric- 10 possible points
Points: 1
Points: 3
Points: 4
Points: 1
Points: 2
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Levels of Achievement
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Criteria
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Emerging
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Competence
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Proficiency
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Mastery
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Subjective
(4 Pts)
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Missing components such as biographic data, medications, or allergies. Symptoms analysis is incomplete. May contain objective data.
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Basic biographic data provided. Medications and allergies included. Symptoms analysis incomplete. Lacking detail. No objective data.
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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.
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Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Detailed. No objective data. Information is solely what “client” provided.
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Points: 1
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Points: 2
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Points: 3
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Points: 4
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Objective
(4 Pts)
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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”.
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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.
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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
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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
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Points: 2
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Actual or Potential Risk Factors
(2 pts)
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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.
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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.
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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.
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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.
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Points: 0.5
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Points: 1.5
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This client is a 23-year-old white female complaining of a painful, swollen ankle. States that she stepped ‘funny’ off a step two days ago and thinks she heard a ripping sound. She takes no medications and has no allergies. The client reports pain as 5/10 with sharp twinges when trying to walk, a notable limp is noted when the client walks favoring the affected extremity. She states resting and ice decreases pain to 2/10 aching. Pain is primarily in the outer aspect of ankle and foot. Has no prior injury to this area. No significant past medical history.” When you examine the ankle the outer aspect of the malleolus is swollen and reddened with 2+ edema noted to the area, pedal pulses are palpable and strong.
In terms of your objective findings, remember to only record what you have assessed. Do not make a diagnosis or state the cause of a particular finding.You are not coming to any conclusions within your documentation. You are simply documenting subjective and objective findings. When your documentation is complete, you will note any findings that were abnormal.
2
Clients Presentation:
Subjective Data (4 points):
Objective Data (4 points):
Describe 2 Actual/Potential Risk Factors ( 2 points):
