Purpose of Assignment:

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

Course Competency:

Select appropriate physical examination skills for the cardiovascular and peripheral vascular 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].

Smith, L. S. (2001, September). Documentation do’s and don’ts. Nursing, 31(9), 30.

Documentation Grading Rubric- 10 possible points