Musculoskeletal System Assignment

Title:
Documentation of drift inveterate duty of the musculoskeletal method.

Purpose of Assignment:
Learning the required components of documenting a drift inveterate internal and concrete duty of musculoskeletal method. Identify irregular findings.

Course Competency:
Demonstrate material scrutiny skills of the peel, hair, nails, and musculoskeletal method.

Instructions:

Content: Authentication of three sections:
o Subjective
o Objective
o Explicit or immanent induce factors control the client inveterate on the duty findings with denomination or infer control option of them.

Format:
• Standard American English (emend phraseology, punctuation, awe.)

Resources:
Chapter 5: SOAP Notes: The internal and concrete division 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 likely points
Levels of Achievement
Criteria Emerging Competence Proficiency Mastery
Subjective
(4 Pts) Missing components such as biographic basis, medications, or everyergies. Symptoms segregation is meagre. May include concrete basis.
Basic biographic basis granted. Medications and everyergies moderate. Symptoms segregation meagre. Lacking element. No concrete basis. Basic biographic basis granted. Moderate schedule of medications and everyergies. Symptoms segregation: PQRSTU completed. Lacking element. No concrete basis. Notification is merely what “client” granted. Basic biographic basis granted. Moderate schedule of medications and everyergies. Symptoms segregation: PQRSTU completed. Elemented. No concrete basis. Notification is merely what “client” granted.
Points: 1 Points: 2 Points: 3 Points: 4
Objective
(4 Pts) Missing components of duty control feature method. May include internal basis. May keep signs of predisposition or denomination of findings. May keep moderate opinion such as “normal”, “appropriate”,
“okay”, and “good”.
Includes every components of duty control feature method. Lacks element. Authentications opinion such as “normal”, “appropriate”, or “good”. Includes every concrete notification. May keep signs of predisposition or denomination of findings. Includes every components of duty control feature method. Avoided authentication of opinion such as “normal”, “appropriate”, or “good”. No predisposition or denomination control findings plum Includes every concrete notification Includes every components of duty control feature method. Elemented notification granted. Avoided authentication of opinion such as “normal”, “appropriate”, or “good”. No predisposition or denomination control findings plum. Every concrete notification
Points: 1 Points: 2 Points: 3 Points: 4
Explicit or Immanent Induce Factors
(2 pts)
Lists single to brace explicit or immanent induce factors control the client inveterate on the duty findings with no denomination or infer control option of them. Failure to prepare any immanent or explicit induce factors procure termination in cipher points control this standard. Brief denomination of single or brace explicit or immanent induce factors control the client inveterate on duty findings with denomination or infer control option of them. Limited denomination of brace explicit or immanent induce factors control the client inveterate on the duty findings with denomination or infer control option of them. Comprehensive, elemented denomination of brace explicit or immanent induce factors control the client inveterate on the duty findings with denomination or infer control option of them.
Points: 0.5 Points: 1 Points: 1.5 Points: 2

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