Module 07 Content

1. You will perform a history of a neurologic problem that your instructor has provided you or one that you have experienced and perform an assessment of the neurologic system. You will document your subjective and objective findings, identify actual or potential risks, and submit this in a Word document to the drop box provided.

Title:

Documentation of problem based assessment of the neurological system.

Purpose of Assignment: 

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

Course Competency:

Apply assessment techniques for the neurological and respiratory systems.

Instructions:

Content: Use of three sections: 

o Subjective

o Objective

o 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

Subjective 

(4 Pts)

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 “client” provided.

Objective

(4 Pts)

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 “normal”, “appropriate”,
  “okay”, and “good”.

Includes all   components of assessment for particular system. Lacks detail. Uses words such   as “normal”, “appropriate”, or “good”. 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   “normal”, “appropriate”, or “good”. 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   “normal”, “appropriate”, or “good”. No   bias or explanation for findings evident. All objective information 

Points: 1

Points: 2

Points: 3

Points: 4

Actual or Potential Risk Factors

(2 pts)

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. 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.