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.
Prioritize appropriate assessment techniques for the gastrointestinal, breasts, and genitourinary systems.
Content:Â Use of three sections:
Â· Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.
Â· Standard American English (correct grammar, punctuation, etc.)
Chapter 5: SOAP Notes: The subjective and objective portion only
Sullivan, D. D. (2012).Â Guide to clinical documentation.Â [E-Book]. Retrieved fromÂ 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 doâ€™s and donâ€™ts.Â Nursing, 31(9), 30. Retrieved fromÂ 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
|Levels of Achievement|
|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 solely what â€œclientâ€ provided.||Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Detailed. No objective data. Information is solely what â€œclientâ€ provided.|
|Points: 1||Points: 2||Points: 3||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 â€œnormalâ€, â€œappropriateâ€, â€œokayâ€, and â€œgoodâ€.
|Includes all components of assessment for particular system. Lacks detail. Uses words such as â€œnormalâ€, â€œappropriateâ€, or â€œgoodâ€. 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 â€œnormalâ€, â€œappropriateâ€, or â€œgoodâ€. 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 â€œnormalâ€, â€œappropriateâ€, or â€œgoodâ€. No bias or explanation for findings evident. All objective information|
|Points: 1||Points: 2||Points: 3||Points: 4|
|Actual or Potential Risk Factors
|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.Â 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.||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: 0.5||Points: 1||Points: 1.5||Points: 2|
Are you busy and do not have time to handle your assignment? Are you scared that your paper will not make the grade? Do you have responsibilities that may hinder you from turning in your assignment on time? Are you tired and can barely handle your assignment? Are your grades inconsistent?
Whichever your reason is, it is valid! You can get professional academic help from our service at affordable rates. We have a team of professional academic writers who can handle all your assignments.
Students barely have time to read. We got you! Have your literature essay or book review written without having the hassle of reading the book. You can get your literature paper custom-written for you by our literature specialists.
Do you struggle with finance? No need to torture yourself if finance is not your cup of tea. You can order your finance paper from our academic writing service and get 100% original work from competent finance experts.
While psychology may be an interesting subject, you may lack sufficient time to handle your assignments. Don’t despair; by using our academic writing service, you can be assured of perfect grades. Moreover, your grades will be consistent.
Engineering is quite a demanding subject. Students face a lot of pressure and barely have enough time to do what they love to do. Our academic writing service got you covered! Our engineering specialists follow the paper instructions and ensure timely delivery of the paper.
In the nursing course, you may have difficulties with literature reviews, annotated bibliographies, critical essays, and other assignments. Our nursing assignment writers will offer you professional nursing paper help at low prices.
Truth be told, sociology papers can be quite exhausting. Our academic writing service relieves you of fatigue, pressure, and stress. You can relax and have peace of mind as our academic writers handle your sociology assignment.
We take pride in having some of the best business writers in the industry. Our business writers have a lot of experience in the field. They are reliable, and you can be assured of a high-grade paper. They are able to handle business papers of any subject, length, deadline, and difficulty!
We boast of having some of the most experienced statistics experts in the industry. Our statistics experts have diverse skills, expertise, and knowledge to handle any kind of assignment. They have access to all kinds of software to get your assignment done.
Writing a law essay may prove to be an insurmountable obstacle, especially when you need to know the peculiarities of the legislative framework. Take advantage of our top-notch law specialists and get superb grades and 100% satisfaction.
We have highlighted some of the most popular subjects we handle above. Those are just a tip of the iceberg. We deal in all academic disciplines since our writers are as diverse. They have been drawn from across all disciplines, and orders are assigned to those writers believed to be the best in the field. In a nutshell, there is no task we cannot handle; all you need to do is place your order with us. As long as your instructions are clear, just trust we shall deliver irrespective of the discipline.
Our essay writers are graduates with bachelor's, masters, Ph.D., and doctorate degrees in various subjects. The minimum requirement to be an essay writer with our essay writing service is to have a college degree. All our academic writers have a minimum of two years of academic writing. We have a stringent recruitment process to ensure that we get only the most competent essay writers in the industry. We also ensure that the writers are handsomely compensated for their value. The majority of our writers are native English speakers. As such, the fluency of language and grammar is impeccable.
There is a very low likelihood that you won’t like the paper.
Not at all. All papers are written from scratch. There is no way your tutor or instructor will realize that you did not write the paper yourself. In fact, we recommend using our assignment help services for consistent results.
We check all papers for plagiarism before we submit them. We use powerful plagiarism checking software such as SafeAssign, LopesWrite, and Turnitin. We also upload the plagiarism report so that you can review it. We understand that plagiarism is academic suicide. We would not take the risk of submitting plagiarized work and jeopardize your academic journey. Furthermore, we do not sell or use prewritten papers, and each paper is written from scratch.
You determine when you get the paper by setting the deadline when placing the order. All papers are delivered within the deadline. We are well aware that we operate in a time-sensitive industry. As such, we have laid out strategies to ensure that the client receives the paper on time and they never miss the deadline. We understand that papers that are submitted late have some points deducted. We do not want you to miss any points due to late submission. We work on beating deadlines by huge margins in order to ensure that you have ample time to review the paper before you submit it.
We have a privacy and confidentiality policy that guides our work. We NEVER share any customer information with third parties. Noone will ever know that you used our assignment help services. It’s only between you and us. We are bound by our policies to protect the customer’s identity and information. All your information, such as your names, phone number, email, order information, and so on, are protected. We have robust security systems that ensure that your data is protected. Hacking our systems is close to impossible, and it has never happened.
You fill all the paper instructions in the order form. Make sure you include all the helpful materials so that our academic writers can deliver the perfect paper. It will also help to eliminate unnecessary revisions.
Proceed to pay for the paper so that it can be assigned to one of our expert academic writers. The paper subject is matched with the writer’s area of specialization.
You communicate with the writer and know about the progress of the paper. The client can ask the writer for drafts of the paper. The client can upload extra material and include additional instructions from the lecturer. Receive a paper.
The paper is sent to your email and uploaded to your personal account. You also get a plagiarism report attached to your paper.
Delivering a high-quality product at a reasonable price is not enough anymore.
That’s why we have developed 5 beneficial guarantees that will make your experience with our service enjoyable, easy, and safe.
You have to be 100% sure of the quality of your product to give a money-back guarantee. This describes us perfectly. Make sure that this guarantee is totally transparent.Read more
Each paper is composed from scratch, according to your instructions. It is then checked by our plagiarism-detection software. There is no gap where plagiarism could squeeze in.Read more
Thanks to our free revisions, there is no way for you to be unsatisfied. We will work on your paper until you are completely happy with the result.Read more
Your email is safe, as we store it according to international data protection rules. Your bank details are secure, as we use only reliable payment systems.Read more
By sending us your money, you buy the service we provide. Check out our terms and conditions if you prefer business talks to be laid out in official language.Read more