You will perform a history of a respiratory problem that either your instructor has provided you or one that you have experienced and perform a respiratory assessment. You will document your subjective and objective findings, identify actual or potential risks, Respiratory System Assignment

Title:

Documentation of problem based assessment of the respiratory system.

Purpose of Assignment:

Learning the required components of documenting a problem based subjective and objective assessment of respiratory system. Identify abnormal findings.

Course Competency:

Apply assessment techniques for the neurological and respiratory 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 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