Documentation of problem based assessment of the nose, throat, neck, and regional lymphatics.
Purpose of Assignment:
Learning the required components of documenting a problem based subjective and objective assessment of nose, throat, neck, and regional lymphatics. Identify abnormal findings.
Course Competency:
Demonstrate physical examination skills of the head, ears, and eyes, nose, mouth, neck, and regional lymphatics.
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).
